COLUMB1Al.^R.|S0^1!11 


HX641 38593 

RC898.M95  Tuberculosis  oi  the 


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Columbia  ©ntoeraitp 

College  of  pfjpgtctans  anb  burgeons 
Htbrarp 


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P^: 


Tuberculosis  of  the  Testicle 

THaitb  Special  Consideration  of 
fits  Conservative  {Treatment. 


(^>    »t    »» 


JOHN  B.  MURPHY,  M.D. 
Chicago 


loir 


558 


TUBERCULOSIS  OF  THE  TESTICLE. 

WITH    SPECIAL     CONSIDERATION     OF    ITS     CONSERVATIVE 
TREATMENT. 


JOHN  B.  MURPHY,  M.D. 

CHICAGO. 


Before  entering  into  our  subject,  let  us  briefly  review 
the  anatomy  and  physiology  of  the  testicle,  that  we  may 
better  understand  the  pathologic  changes  and  processes 
of  repair  which  take  place  when  it  is  the  seat  of  tuber- 
cular infection. 

The  testes  are  suspended  in  the  scrotum  by  the  two 
spermatic  cords,  the  left  being  slightly  lower  than  the 
right.  Each  is  oval  in  form,  compressed  laterally,  and 
occupies  an  oblique  position  in  the  scrotum,  the  upper 
extremity  being  directed  forward  and  outward,  and  the 
lower  downward  and  a  little  inward.  The  surface  of 
the  gland,  excepting  its  posterior  border,  is  free,  smooth 
and  covered  by  the  visceral  layer  of  the  tunica  vagi- 
inalis.  Lying  along  the  posterior  border  is  a  narrow 
flattened  body,  the  epididymis,  which  consists  of  three 
parts,  namely,  first,  the  upper  enlarged  extremity, 
globus  major;  second,  the  pointed  lower  extremity, 
globus  minor,  and,  third,  the  intermediate  portion,  or 
body  of  the  epididymis.  The  globus  major  is  intimately 
connected  with  the  upper  end  of  the  testicle  proper  by 
means  of  its  efferent  ducts,  while  the  globus  minor  is 
attached  to  its  lower  end  by  cellular  tissue  and  a  reflec- 
tion of  the  tunica  vaginalis.  This  membrane,  the  tunica 
vaginalis,  as  it  leaves  the  testicle  proper  at  its  posterior 
border,  is  reflected  on  to  the  epididymis,  covering  its 
outer  surface  and  upper  and  lower  extremities  and  com- 
pletely investing  the  body,  excepting  along  its  posterior 
border,  from  which  it  is  again  reflected  on  to  the  inner 


2 

surface  of  the  scrotum.  It  will  thus  be  seen  that  a  sort 
of  mesentery  is  formed  by  the  membrane  between  the  tes- 
ticle proper  and  the  epididymis.  Attached  to  the  upper 
end  of  the  testicle  or  epididymis  are  one  or  more  small 
pedunculated  bodies,  the  most  constant  of  which  is 
called  the  "hydatid  of  Morgagni." 

Besides  the  tunica  vaginalis,  which  is  the  most  exter- 
nal, the  Lestis  is  invested  by  two  tunics,  the  tunica  albu- 
a  and  the  tunica  vasculosa.  The  tunica  albuginea  is 
beneath  the  serous  coat  and  surrounds  the  glandular 
structure  of  the  testis.  It  is  thick  and.  dense,  and  com- 
id  of  white  fibrous  tissue.  At  the  posterior  border 
of  the  gland  it  is  reflected  into  the  interior,  forming  an 
incomplete  vertical  septum,  the  mediastinum  testis,  or 
corpus  Highmorianum,  from  the  edge  and  lateral  sur- 
faces of  which  numerous  fibrous  trabecular  pass,  to  be 
attached  to  the  inner  surface  of  the  tunica  albuginea. 
These  trabecular  divide  the  interior  of  the  gland  into  a 
number  of  cone-shaped  spaces,  the  bases  of  the  cones 
being  at  the  periphery  and  the  apices  at  the  mediastinum. 
The  tunica  vasculosa  consists  of  a  plexus  of  blood-vessels, 
which  line  the  inner  surface  of  the  tunica  albuginea  and 
the  fibrous  trabecular. 

The  glandular  structure  of  the  testis  (Fig.  A)  con- 
sists of  numerous  cone-shaped  lobules  (lobuli  testis), 
each  contained  in  one  of  the  spaces  described  above  and 
composed  of  one  or  more  convoluted  tubules,  2*4  feet  in 
length  and  1/150  inch  in  diameter,  the  convolutions  be- 
ing held  together  by  an  intertubular  connective  tissue. 
,  The  connective  tissue  presents  large  interstitial  spaces 
lined  with  endothelium,  the  rootlets  of  the  lymphatic 
vessels,  and  masses  of  large  cells — the  interstitial  cells — 
accompanying  the  finer  blood-vessels. 

Each  seminiferous  tubule  consists  of:  1,  a  hyaline 
membrana  propria  ;  2,  several  layers  of  epithelial  cells — 
the  seminal  cells — which  are  usually  arranged  as  fol- 
lows: a,  an  outer  (deeper)  layer  of  polyhedral  cells,  the 
spermatogoma ;  h,  an  intermediate  layer,  the  cells  of 
which  are  in  active  proliferation,  the  spermatogenie 
cells ;  c,  an  inner  layer,  the  spermatoblasts.  The  latter 
are  granular,  indistinctly  outlined,  and  show  no  signs 
of  proliferation. 

At  the  apices  of  the  lobules  the  tubes  become  straight, 
join  together  to  form  larger  tubes  (vasa  recta),  and  en- 


3 

ter  channels  in  the  mediastinum  (rete  testis).  At  the 
upper  end  of  the  mediastinum  the  channels  of  the  rete 
unite  to  form  from  13  to  20  larger  tubes  (vasa  efferen- 
tia),  which  perforate  the  tunica  albuginea  and  enter  the 
epididymis.  At  first  straight,  they  become  convoluted 
and  form  a  series  of  cone-shaped  masses  (coni  vascu- 
losis which  together  form  the  globus  major.  Opposite 
the  bases  of  the  cones  the  efferent  vessels  open  at  narrow 
intervals  into  a  single  duct,  which  constitutes,  by  its 
complex  convolutions,  the  body  and  globus  minor  of  the 
epididymis.  This  tube,  the  convolutions  of  which  are 
held  together  by  fine  areolar  tissue,  is  about  20  feet  in 
length,  and  is  continuous  at  the  globus  minor  with  the 
vas  deferens. 

The  vasa  recta  and  channels  of  the  rete  are  lined  by 
a  single  layer  of  flattened  epithelial  cells.  The  vasa  ef-- 
ferentia  and  tube  of  the  epididymis  are  lined  by  colum- 
nar ciliated  epithelium,  and  their  walls  contain  circu- 
larly arranged  muscular  fibers. 

The  vas  deferens  is  a  continuation  of  the  tube  of  the 
epididymis.  (See  Fig.  1.)  Commencing  at  the  lower 
part  of  the  globus  minor,  it  ascends  along  the  posterior 
border  of  the  testis  and  inner  side  of  the  epididymis, 
and  along  the  back  part  of  the  cord  to  the  internal  ring. 
From  the  ring  it  curves  around  the  epigastric  artery  and 
descends  into  the  pelvis  at  the  side  of  the  bladder  to  its 
base.  In  this  situation  it  lies  between  the  bladder  and 
rectum  and  along  the  inner  border  of  the  seminal  vesicle 
of  the  same  side.  Here  it  becomes  enlarged  to  form  the 
ampulla,  then  narrows  and  unites  with  the  duct  of  the 
vesicula  seminalis  to  form  the  ejaculatory  duct.  It  is 
about  2  feet  in  length,  the  walls  are  thick  and  the  lumen 
small,  measuring  1/25  of  an  inch.  The  vas  consists  of 
three  coats:  1,  an  external  or  cellular  coat;  2,  a  mus- 
cular coat;  and,  3,  an  internal  or  mucous  coat,  arranged 
in  longitudinal  folds  and  covered  by  columnar  epi- 
thelium. 

The  blood-supply  of  the  testis  is  principally  from  the 
spermatic  artery,  which  arises  from  the  abdominal  aorta, 
and  accompanies  the  other  structures  composing  the 
cord  through  the  canal.  As  it  approaches  the  testicle 
it  divides,  some  small  branches  continuing  onward  to 
supply  the  epididymis,  while  the  larger  ones  perforate 
the  tunica  albuginea  and  enter  the  mediastinum  to 
supply  the  glandular  portion  through  the  vessels  of  the 


tunica  \  asm  Id- a.  The  vessel  does  not  always  divide  so 
high  as  is  pictured  in  the  text-books.  This  is  shown  in 
Fig.  :.',  where  the  artery  was  injected  with  mercury  and 
then  skiagraphed.  The  bifurcation  takes  place  close  to 
i  lif  testicle,  a  fact  to  be  borne  in  mind  when  operating. 

The  spermatic  veins  commence  in  the  testis  and  epi- 
didymis, pass  out  at  the  posterior  border  and  ascend  in 
the  cord  as  the  pampiniform  plexus.  (See  skiagraph 
Fig.  No.  3.)  Finally,  two  or  three  larger  veins  are 
formed  from  the  plexus,  pass  into  the  abdomen  with  the 
artery  and  unite  to  form  the  spermatic  vein.  This,  on 
the  left  side,  empties  into  the  renal  vein,  and  on  the 
right  side  into  the  ascending  vena  cava. 

The  lymphatics  of  the  testicle  (see  Fig.  4)  commence 
as  minute  vessels  around  the  seminal  tubules.  These 
coalesce  and  most  of  them  pass  through  the  septa  into 
the  mediastinum.  Others  pass  outward  to  join  the 
plexus  beneath  the  tunica  albuginea,  which  plexus  also 
communicates  with  a  more  superficial  one  beneath  the 
tunica  vaginalis.  Tn  the  mediastinum  the  deep  and 
superficial  sets  unite  to  form  from  four  to  six  trunks, 
which  pass  upward  in  the  cord  into  the  abdomen.  On 
the  left  side  these  vessels  enter  the  glands  near  the 
aorta  and  left  renal  vein,  while  on  the  right  they  empty 
into  the  lumbar  glands  just  above  the  bifurcation  of 
the  aorta.  Afferent  vessels  from  the  glands  of  both  sides 
empty  into  the  reeeptaculum  chyli. 

The  nerves  are  derived  from  the  sympathetic  system, 
branches  from  the  aortic,  renal  and  hypogastric  plexuses, 
forming  the  spermatic  plexus,  which  descends  upon  the 
spermatic  artery  and  artery  of  the  vas  deferens.  They 
are  not  provided  with  ganglia  and  have  not  been  traced 
into  the  tubules.  The  terminal  filaments  ramify  on  the 
surface  of  the  tubules  and  are  distributed  to  the  blood- 
vessels. 

Physiology. — The  functions  of  the  testicle  are  two  in 
number:  1,  the  production  of  spermatozoa;  2,  the  for- 
mation of  an  internal  secretion,  which  is  necessary  to 
normal  metabolism. 

The  spermatozoa  are  formed  in  the  seminiferous  tu- 
bules by  a  series  of  changes  which  take  place  in  the 
spermatoblasts,  or  cells  of  the  internal  layer.  These 
changes  are  as  follows:  The  cell  first  assumes  a  pear- 
shape,  the  pointed  end  containing  the  nucleus,  being 
directed  toward   the  basement  membrane.     This  por- 


tion  forms  the  head  of  the  spermatozoon.  By  a  drawing 
out  or  elongation  of  the  broad  part  of  the  cell  the  middle 
piece  and  tail  are  formed. 

After  puberty  the  semen  is  probably  being  constantly 
secreted,  although  most  of  the  time  in  small  quantities. 
As  the  spermatozoa  are  formed  they  are  forced  along 
the  tubules  by  the  pressure  of  accumulated  secretion, 
3,4        H 


Fig.  A. — Showing  testicle  partly  macerated  in  KOH  solution, 
which  has  loosened  the  connective  tissue  framework.  (After 
Toldt.)  1.  Tubuli  seminiferi  contorti.  2.  Body  of  epididymis.  3. 
Coni  vasculosi.  4.  Vasa  efferentia.  5.  Tunica  albuginea  at  hylum 
6.   Lobuli  testis.    7.   Tubuli  seminiferi. 


aided  by  the  ciliary  movements  of  the  cells  lining  the 
vasa  recta,  vasa  efferentia  and  tube  of  the  epididymis. 
In  the  two  latter  its  expulsion  is  also  aided  by  contrac- 
tion of  the  muscular  fibers  in  their  walls.  From  the  vas 
deferens   the   semen    passes    into   the   ejaeulatory   duct 


(i 

and  seminal  vesicle,  in  which  latter,  unless  discharged 
immediately  by  emission,  some  of  it  is  retained.  It  is 
probable,  however,  that  the  principal  function  of  the 
vesiculae  seininales  is  seeretory  and  that  the  ducts  of 
the  testes,  rather  than  they,  act  as  reservoirs  for  the 
semen. 

The  second  and  more  important  function  of  the  testi- 
cles is  the  formation  of  an  internal  secretion.  While 
the  active  principle  of  this  secretion  has  never  been 
isolated,  nor  the  secretion  itself  been  definitely  proved 
to  exist,  experimental  and  pathologic  evidence  leaves 
little  doubt  as  to  its  presence  under  normal  conditions. 
Its  importance  to  the  normal  development  of  the  body 
is  shown  in  cases  of  cryptorchismus,  or  where  both  testi- 
cles have  been  destroyed  or  removed  before  the  age  of 
puberty.  These  cases  invariably  show  a  lack  of  the 
sexual  characteristics  which  are  normally  developed  at 
this  time.  Its  influence  is  also  shown,  though  to  a  lesser 
degree,  in  cases  where  both  organs  have  been  removed 
after  puberty  in  early  and  middle  adult  life.  In  many 
of  these,  sexual  desire  is  entirely  lost,  the  prostate  and 
other  parts  of  the  remaining  genital  apparatus  atrophy, 
and  in  a  few  there  is  a  loss  of  the  sexual  characteristics 
which  were  formerly  possessed.  The  experiments  of 
Zath,  reported  in  1896,  are  interesting  in  this  connec- 
tion. Under  daily  injections  of  testicular  extract  the 
working  power  of  a  man's  neuro-muscular  system  was 
increased  5  per  cent.,  and  during  rest  his  powers  of  re- 
cuperation weTe  greatly  increased. 

It  can  thus  be  seen  that  the  preservation  of  this 
normal  secretion  is  worthy  of  careful  consideration,  and 
the  purpose  of  this  paper  is  to  emphasize  its  impor- 
tance. In  addition  to  the  physiologic  effects  on  the  gen- 
eral metabolism  produced  by  the  removal  of  the  testes., 
in  many  cases  grave  mental  states,  such  as  melancholia, 
are  induced.  Finally,  there  is  the  practical  side,  that 
many  patients  will  not  consent  to  the  removal  of  both 
testes  for  tubercular  disease  until  the  bladder  and  pros- 
tate have  become  involved,  or  until  they  realize  that 
death  will  result  if  the  diseased  organs  are  retained. 
while  they  will  readily  consent  to  the  removal  of  both 
epididvmi,  upon  the  physician's  statement  that  the  tes- 
ticles proper  will  be  preserved. 

FJiolnqn.  A  nn ■■ — Tuberculosis  of  tho  focfiHo  mav 
occur  at  anv  nco,  lmt  it   i<s  muHi  morn  pommori  during 


early  adult  life,  between  the  ages  of  20  and  35  years, 
when  the  activity  of  the  sexual  gland  is  at  its  height. 
In  Koenig's  cases  the  different  decades  were  affected 
as  follows :  Under  4  years,  3 ;  between  20  and  30  years, 
24;  between  30  and  40  years,  8;  between  40  and  50 
year's,  4;  between  50  and  GO  years,  4;  between  60  and 
80  years,  2.  Of  the  latter,  one  was  67,  and  one  72 
years  of  age. 

The  age  statistics  quoted  by  Senn  from  the  various 
authorities  are  as  follows:  Sallerton  in  47  cases  ob- 
served the  period  of  greatest  liability  to  be  between 
20  and  30  years.  Kocher  from  50  cases  also  between 
20  and  30  years,  while  Simonds,  from  an  analysis  of 


Fig.   1. — Skiagraph   showing  Vas  and  Tube  of  the  epididymis  In- 
jected with  mercury,     a,  Vas.     ft.  Tube  of  epididymis. 

69  cases,  found  the  greatest  number  between  the  ages 
of  40  and  50  years,  with  20  to  30,  and  30  to  40  years 
coming  next  in  frequency. 

Jullien  reported  16  cases  of  tubercular  testicle  in 
infants,  6  of  which  were  under  1  year  of  age,  and  Dr. 
Dreschfeld  a  case  where  the  disease  was  present  at  birth. 
In  one  of  Koenig's  cases  the  disease  was  noted  a  few 
days  after  birth. 

As  regards  the  other  extreme  of  life,  Gibson  has  re- 
ported a  case  in  a  man  aged  81  years.  In  the  cases  here 
reported  the  average  age  was  about  33  years. 

Hereditary  Influence. — This  may  be  shown  in  two 
ways  :  1,  where  the  disease  is  present  at  birth  or  develops 


very  soon  after;  J.  as  an  inherited  condition  of  lowered 
vitality,  in  which  there  is  a  tendency  to  the  development 
of  tuberculosis,  due,  probably,  to  a  lessened  resistance 
of  the  tissues. 

In  perhaps  the  majority  of  the  cases  no  tubercular 
family  history  can  be  obtained,  this  absence  of  hered- 
itary influence  being  especially  marked  in  cases  which 
develop  in  adult  life.  In  10  cases  of  testicular  tuber- 
culosis in  children,  reported  by  Jullien  and  Lanne- 
longue,  4  presented  a  distinct  family  historv.  In  5 
of  Koenig's  cases,  in  which  the  disease  was  distinctly 
localized  in  the  testis,  and  in  which  he  believed  it  to 
have  originated  from  pre-existing  tubercular  deposit, 
there  was  a  family  history  in  3. 

In  16  cases  reported  by  Jullien,  6  were  in  patients  less 
than  one  year  of  age.  An  inherited  tendency  is  prob- 
ably present  where  the  disease  develops  so  soon  after 
birth. 

Injury. — In  many  cases  there  is  a  history  of  trau- 
matism preceding  the  onset  of  the  disease.  The  injury 
in  most  cases,  slight  and  insignificant,  may  be  forgotten 
by  the  patient,  who  does  not  connect  it  with  the  onset 
of  his  trouble.  In  other  cases  the  relation  between  the 
two  is  so  striking  and  direct  that  it  can  not  be  over- 
looked. This  etiologic  factor  is  beautifully  illustrated 
in  Case  10,  where  the  disease  developed  almost  imme- 
diately after  a  kick  in  the  testicle.  The  rule  is  that 
the  tubercular  process  does  not  manifest  itself  con- 
spicuously until  at  least  six  weeks  or  more  have  elapsed 
from  the  time  the  injury  was  received. 

Previous  Inflammatory  Processes. — Of  all  affections 
of  the  genito-urinary  tract,  which  predispose  the  testi- 
cle and  epididymis  to  a  subsequent  tubercular  infection, 
gonorrhea  is  the  most  important,  either  a  gonorrheal 
epididymitis  or  a  posterior  urethritis.  In  52  cases  col- 
lided by  Kocher,  14  had  suffered  from  it  previously. 
The  tubercular  process  may  follow  the  gonorrheal  im- 
mediately, while  the  latter  is  yet  in  the  acute  stage,  or 
at  any  time  after  the  subsidence  of  the  active  symptoms. 
It  must  not  be  forgotten,  however,  in  this  connection, 
that  the  gonorrheal  inflammation  may  be  simply  the 
means  of  lighting  up  a  latent  tubercular  focus,  which 
had  been  lying  dormant  in  the  epididymis  for  years, 
without,  perhaps,  the  patient  being  aware  of  its  exist- 
ence. 


The  explanation  of  this  phenomenon  is  simply  that 
of  a  locus  minoris  residential  left  after  subsidence  of 
the  acute  inflammatory  process.  This  area  of  dimin- 
ished resistance  may  perhaps  in  some  cases  be  a  defect 
in  the  mucous  lining,  through  which  germs  may  enter 
from  the  surface.  Tuberculosis  of  the  testicle  does  not 
commonly  follow  the  acute  infectious  diseases,  even 
when  these  have  been  complicated  by  an  orchitis.  J.  B. 
Shaw  reports  a  case  where  it  was  supposed  to  have  fol- 
lowed an  attack  of  measles. 


Fig.  2. — Skiagraph  of  Spermatic  Artery  injected  with  mercury. 
a.  Spermatic  Artery,  b.  Branch  to  epididymis,  c.  Branch  to 
testicle  proper. 

Atrium  of  Infection. — This  at  the  present  time  is 
undergoing  most  rigid  scientific  investigations.  The 
channels  through  which  infection  may  take  place  are, 
in  order  of  frequency,  as  follows :  1,  respiratory  tract ; 
2,  gastrointestinal  tract ;  3,  genitourinary  tract ;  4,  skin. 

That  the  respiratory  tract,  with  arrest  of  infecting 
organisms  in  the  mediastinal  glands,  is  the  most  fre- 
quent atrium  of  infection,  is  shown  by  the  researches 
of  Jens  Bugge.  This  investigator  has  shown  that  75 
per  cent,  of  all  human  beings  who  come  to  the  post- 


1(1 

mortem  table  have  had  mediastinal  glandular  tubercu- 
losis. As  is  well  known,  this  disease  may  exist  without 
producing  any  symptoms,  and  it  will  therefore  be  seen 
how  readily  a  crypto-tubercular  infection  in  this  locality 
could  precede  a  localized  infection  of  the  testicle.  It 
is  our  belief  that  the  mediastinal  glands  are  the  most 
common  sources  of  supply  for  tubercle  bacilli  in  the 
body. 

Carious  teeth  with  ulceration  of  the  gums  about  them, 
and  defects  in  the  mucous  membrane  of  the  nose,  mouth, 
ronsils  and  middle  ear,  with  subsequent  infection  of 
the  cervical  lymph-glands  may,  especially  in  children, 
be  the  primary  sources  of  infection. 

That  the  gastrointestinal  tract  admits  of  infection 
from  tuberculous  material  taken  in  as  food,  can  not 
be  questioned,  but  that  it  is  attacked  much  less  common- 
ly than  is  generally  supposed  is  proved  by  the  infre- 
quency  of  tuberculosis  of  the  mesenteric  glands. 
(Northrup  and  Boviard.)  Dr.  W.  J.  Mayo,  of  Minne- 
sota, has  found  that  in  the  rural  districts,  where  milk 
is  largely  used  as  an  article  of  diet,  a  localized  tuber- 
culosis of  the  intestinal  mucosa  is  not  very  uncommon, 
but  that  the  mesenteric  glands  are  very  rarely  involved 
without  a  demonstrable  lesion  in  the  intestine.  In 
this  respect  the  intestinal  tract  differs  from  the  respira- 
tory, where  in  many  cases  no  physical  changes  can  be 
demonstrated  at  the  point  where  the  bacilli  have  gained 
entrance. 

That  infection  can  take  place  directly  through  the 
urinary  outlet,  the  urethra,  or  through  the  genital  out- 
let, the  vagina,  is  generally  admitted,  and  cases  have 
been  reported  where  it  was  transmitted  from  a  tubercu- 
lar uterus  or  vagina  to  the  glans  penis,  or  prepuce. 
(Jonin,  Cornet.)  Reclus  denies  that  infection  ever 
takes  place  in  this  way. 

That  tubercular  infection  is  often  admitted  into 
the  system  through  the  skin  is  shown  by  the  number 
of  cases  of  the  local  disease  among  physicians,  and  in 
the  children  of  tuberculous  parents,  these  children  so 
often  developing  lesions  about  the  cheeks,  lips  and 
mouth. 

The  tubercle  bacilli  having  gained  entrance  into  the 
system,  the  next  subject  for  consideration  is :  How  do 
they  find  localization  in  the  testis?  There  are  a  number 
of  routes  by  which  the  infection  mav  be  carried  to  the 


u 


sexual  glands:  1,  by  the  blood-stream;  2,  along  the 
surface  of  the  mucous  membrane  of  the  genito-urinary 
tract;    3,  by  the  lymphatics. 

1.  Transmission  by  the  blood-stream  has  been,  by 
most  authors,  considered  to  be  the  most  important. 
The  bacilli  contained  in  the  blood  localize  in  the  epi- 
didymis at  some  point  M'here  there  exists  a  focus  of 
diminished   resistance,   either   congenital,   or  produced 


3. — Spermatic  Veins  injected   with   mercury. 


by  previous  injury  or  disease.  The  frequent  localiza- 
tion in  the  epididymis  is  accounted  for  by  the  fact  that 
the  spermatic  artery  divides  opposite  that  organ,  and 
that  the  vessels  of  the  epididymis  are  smaller  and  more 
tortuous  than  those  of  the  vas  or  testicle  proper,  the 
current  therefore  being  slower  .     (Saltzman.) 

2.  In  some  cases  the  infection  undoubtedly  travels 
along  the  surface  of  the  mucous  membrane.  This  view 
is  supported  by  Koenig  in  his  recent  paper  on  the  sub- 


ject.    lie  beli  i  in  a  very  great  majority  of  cases 

the  testicular  affection  is  preceded  by  tubercular  dis- 
higher  up  in  the  genito-urinary  tract,  especially 
in  the  vesiculse  seminales  and  prostate.  In  the  45 
cases  reported  by  him,  these  organs  were  involved  31 
times.  In  the  majority  of  cases,  however,  there  were 
distant  foci  in  the  lungs,  bones,  glands,  etc.  Kocher 
holds  the  .-ante  view.  Cayla  thinks  that  a  descending 
infection  along  the  mucous  membrane  is  most  common, 
and  believes  that  the  infection  travels  in  the  same 
direction  as  the  current  of  urine,  and  against  that  of 
the  semen.  His  views  are  based  on  100  sections,  in 
which  he  observed  that  tubercular  disease  of  the  genito- 
urinary organs  was  always  preceded  by  tuberculosis 
higher  up. 

GuyoD  and  Lancereaux  have  observed  that  the  process 
often  begins  in  the  vesicular  seminales.  Virchow  has 
always  held  that  the  infection  was  a  descending  one, 
beginning  in  some  of  the  higher  genito-urinary  organs. 
Saleron  is  opposed  to  this  view,  as  in  51  cases  examined 
by  him,  organs,  other  than  the  testicles  and  epididymis, 
were  involved  in  only  one  case.  Senn  states  that 
frequently  the  infection  descends  from  the  prostate, 
seminal  vesicles  or  kidneys.  Weigert  (cited  by  Kocher) 
thinks  that  the  prostate  favors  localization  of  all  kinds 
of  micro-organisms,  and  Kcziwicki.  in  15  autopsies  on 
cases  of  genito-urinary  tuberculosis,  found  the  prostate 
involved  11  times. 

M.  Verneuil  believes  that  infection  often  takes  place 
during  coitus,  and  gives  anatomical  reasons  for  his 
views.  This  seems  very  doubtful,  however,  when  we 
consider  the  frequency  of  tubercular  epididymitis  in 
children.  Furthermore,  if  this  were  the  case,  we  should 
more  frequently  meet  with  tubercular  lesions  of  the 
penis  and  urethra,  for  there  must  be  ample  means 
for  inoculation  in  the  abrasions  of  the  urethral  mucosa 
so  commonly  found  in  gonorrhea. 

While  we  can  undoubtedly  have  a  descending  infec- 
tion, it  is  our  observation  and  that  of  many  other  in- 
vestigators, that  the  disease  is  usually  an  ascending 
one,  the  epididymis  being  affected  primarily  and  the 
bladder,  prostate,  etc.,  secondarily,  the  process  ex- 
tending upward  along  the  surface  of  the  mucous  mem- 
brane of  the  excretory  duct. 

3.  Transmission    of   the    infectious    material    to   the 


13 


L*'ig.  4. —  lymphatics  of  testicle.      (Heitzmann.) 


li 

testicle  by  the  lymph  channels,  while  usually  given 
as  one  of  the  routes,  must  be  very  rare,  as  the  lymph- 
curreni  is  directed  away  from  the  organ  rather  than 
toward  it.  Xo  cases  have  been  reported  which  show  the 
infection  to  have  taken  place  in  this  way. 

Koenig  thinks  that  in  some  cases  the  disease  begins 
as  a  primary  tuberculosis  of  the  testicle,  the  infection 
having  been  carried  to  the  organ  some  time  before 
and  remaining  dormant  until  lighted  up  by  the  occur- 
rence of  one  of  the  exciting  causes,  such  as  injury, 
acute  inflammatory  processes,  etc.  This  view  is  based 
on  the  studies  of  Jani,  who  found  bacilli  in  apparently 
healthy  testicles  of  patients  suffering  from  pulmonary 
phthisis.  Koenig  thinks  that  this  may  explain  some 
cases  where  no  atrium  of  infection  can  be  demonstrated. 

Association  of  Tuberculosis  of  the  Testicle  with  Tu- 
bercular Lesions  Elsewhere  in  the  Body. — As  stated 
above,  in  from  73  to  75  per  cent,  of  persons  dying  from 
all  causes,  mediastinal  glandular  tuberculosis  is  present, 
and  this  in  the  majority  of  cases  is  probably  the  atrium 
of  infection  in  the  cases  of  testicular  disease.  The  latter 
is  not  usually  associated  with  pulmonary  tuberculosis, 
though  Reclus  observed  that  50  per  cent,  presented 
lung  findings,  and  2.5  per  cent,  of  the  pulmonary 
cases  over  15  years  of  age  suffered  also  from  local- 
ization in  the  testicle.  In  his  analysis  of  500  cases  of 
phthisis,  64  had  involvement  of  the  genito-urinary 
tract,  45  of  the  genital  tract,  and  in  19  the  testicles 
alone  were  affected.  Simonds.  from  his  post-mortem 
experience,  found  the  genital  organs  involved  in  2 
per  cent,  of  all  tubercular  children. 

Tuberculosis  of  the  lymphatic  glands  and  bones  is 
not  often  accompanied  by  disease  of  the  genital  organs. 

In  children,  tuberculosis  of  the  peritoneum  sometimes 
coexists  with  disease  in  the  testicles.  Reclus  thinks 
there  is,  in  these  cases,  a  communication  between  the 
cavity  of  the  tunica  vaginalis  and  the  peritoneal  cavity, 
the  processus  vaginalis. 

Tillmans  states  that  tuberculosis  of  the  testicle  almost 
always  develops  in  persons  already  tuberculous,  but 
this  is  not  borne  out  by  the  experience  of  most  surgeons. 

Tn  the  majority  of  our  cases  the  disease,  so  far  as 
could  be  determined  by  physical  examination  and  clin- 
ical history,  was  primary  in  the  epididymis. 

As  a  Part  of  a  General  Miliary  Tuberculosis. — This 


is  of  but  little  interest  to  us  in  the  consideration  of 
this  subject,  because  when  it  is  present,  it  is  over- 
shadowed by  the  manifestations  of  the  disease  in  other 
parts.  Koenig  states  that  the  testicles  are  rarely  affect- 
ed in  general  miliary  tuberculosis.  When  the  involve- 
ment does  occur,  both  testicles  and  both  epididymi  are 
affected  simultaneously.  Hutinell  and  Deschamps  state 
that  tuberculosis  of  the  testes  in  children  is  seldom 
primary,  but  usually  a  part  of  a  general  infection. 
Occurrence  of  the  Disease  in  Misplaced  and  Inverted 


Fig.  5. — Showing  involvement  of  testicle  proper  and  epididymis, 
the  former  by  extension  from  latter.  a.  Globus  Major.  6. 
Testicle  proper. 

Testicles. — No  authentic  case  of  tubercular  disease  af- 
fecting an  undescended  testicle  is  on  record,  although 
several  cases  supposed  to  be  such  have  been  reported,  one 
by  G-.  Fischer,  in  1864,  and  another  by  F.  Roberts. 
The  details  of  the  cases  in  these  reports  are  indefinite, 
so  that  it  is  very  doubtful  if  they  were  really  cases  of 
tuberculosis.  No  satisfactory  explanation  of  the  ap- 
parent immunity  possessed  by  these  misplaced  organs 
has  been  offered.  Tn  a  case  reported  by  Rushton 
Parker,  of  general    tuberculosis,   the   left  testicle  was 


in 

:it.  and  the  left  seminal  vesicle  free  from  disease, 
while  the  right  testicle  was  present  and  the  right  vesicle 
involve  d. 

Lnversic-testis  was  noted  by  Koenig  five  times  in 
his  casesj  ami  it  is  thought  by  him  to  he  a  predisposing 
cause.  Case  No.  13  of  our  series  presents  this  anomaly 
in  tin'  testicle  first  attacked. 

The  right  testicle  is  attacked  first  in  the  majority  of 
cases.  Rintelen  (quoted  hy  Senn)  observed  in  15  cases 
that  the  right  organ  was  affected  first  in  10,  and  the 
left  in  5.  In  10  of  our  cases,  in  which  an  accurate 
history  of  the  onset  could  be  obtained,  the  right  was 
involved  first  in  8,  and  the  left  in  2.  Whichever  organ 
is  primarily  attacked,  it  is  usually  only  a  question  of 
time  before  the  other  becomes  similarly  diseased,  this 
extension  being  due,  in  all  probability,  to  transmission 
of  the  infectious  material  along  the  vas  of  the  affected 
side  to  the  prostatic  urethra  and  down  the  opposite 
vas  to  the  epididymis  on  the  other  side.  Jul  lien  states 
that  in  children  the  left  testis  is  commonlv  affected  first. 

PaiJiologij. — There  has  been  and  still  is  a  marked 
diversity  of  opinion  as  to  the  location  of  the  primary 
focus  in  the  testis,  and  its  method  of  extension  sub- 
sequently, and  a  still  greater  divergence  as  to  the  rela- 
tion which  the  testicular  disease  bears  to  tuberculosis 
of  other  portions  of  the  genito-urinary  tract,  or  of 
more  distant  portions  of  the  body. 

The  epididymis  is,  in  a  very  large  percentage  of  the 
cases,  first  attacked.  Cases  have  been  reported  (Reclus) 
in  which  the  disease  began  in  the  testicle  proper,  but 
they  are  so  very  rare  that  practically  they  may  be  ex- 
cluded. Gilbert  Barling,  M.B.,  reports  a  case  of  acute 
tubercular  disease  of  the  bodies  of  both  testicles.  In 
this  case  castration  was  performed,  and  caseous  areas 
and  tubercle  bacilli  were  found  in  the  bodies  of  the 
testicles,  the  epididymi  not  being  involved.  There  was, 
however,  a  suspicion  of  phthisis  in  the  right  apex. 

Most  authors  hold  that  in  the  majority  of  cases  the 
globus  major  is  first  attacked,  the  infection  spreading 
from  there  to  the  body  and  globus  minor,  and  finally 
to  the  testicle  proper.  From  our  own  observations, 
however,  we  would  say  that  in  adult  cases  the  globus 
minor  is  most  frequently  primarily  attacked,  the  body. 
ifloluis  major,  and  mediastinum  testis  becoming  affected 
secondarily   by   continuity    of   tissue,   or   by   extension 


17 


along  the  surfaces  of  the  seminal  ducts.  In  children 
the  primary  nodule  has  usually  been  in  the  globus  major. 
The  morbid  anatomy  of  a  testicle,  the  seat  of  tuber- 
cular disease,  varies  greatly,  depending  on  the  stage 
to  which   the   process   has   advanced,    the   anatomical 


Fig.    6. — Tuberculosis   of    Tunica    Vaginalis,      a.  Tubercular    areas. 
b.   Epididymis,     c.   Healthy  Tunica  Vaginalis. 


distribution  of  the  lesion,  and  the  presence  or  absence 
of  secondary  infection.  We  will  not  consider  here  the 
testicular  affection  which  is  a  part  of  a  general  miliary 


18 

tuberculosis,  In  the  majority  of  Lhe  cases  the  epi- 
didymis is  alone  involved,  and  presents  In  the  early 
stages  one  or  more  small  nodules,  situated  in  the  globus 
minor  or  major.  Later  other  nodules  form  in  different 
parts,  which  enlarge  and  coalesce,  converting  the  epi- 
didymis into  a  hard,  irregularly  shaped  mass,  which, 
at  a  still  Later  period,  after  caseation  and  softening  have 
taken  place,  may  be  soft  and  fluctuating.  Section 
of  the  epididymis  in  the  early  stage  shows  the  nodules 
to  be  composed  of  a  homogeneous  material,  which  has 
Largely  taken  the  place  of  normal  tissue,  the  latter 
being  compressed  and  infiltrated  with  inflammatory 
products.  The  capsule  of  the  epididymis  is  greatly 
thickened,  and  the  vas,  near  its  attachment  to  the  globus 
minor,  may  be  thickened  and  nodular,  due  to  the  infil- 
tration of  the  tissues  surrounding  it,  or  to  an  involve- 
ment of  its  walls  proper.  Later  the  small  nodules  have 
fused  with  one  another  to  form  larger  ones,  the  homo- 
geneous material  may  be  liquefied  so  as  to  resemble 
pus.  Fibrous  tissue  may  have  been  formed  around  some 
of  the  softened  areas,  and  between  them  islands  of 
normal  or  altered  tubular  tissue  may  be  seen.  The 
capsule  now  presents  caseating  areas,  and  the  cellular 
tissues  of  the  scrotum  in  its  neighborhood  may  be 
edematous,  infiltrated  and  adherent  to  it  and  the  skin. 
When  secondary  infection  has  taken  place,  and  fre- 
quently without  it,  the  pus  may  have  burrowed  toward 
the  skin,  the  abscess  cavity  ruptured,  and  a  discharging 
sinus  surrounded  by  thick  fibrous  walls  formed.  The 
fibrous  capsule  which  surrounds  the  caseous  areas  may 
become  infiltrated  with  lime  salts,  and  in  this  way  a 
thick  shell  of  calcareous  material,  surrounding  it  or 
perhaps  the  entire  epididymis,  is  formed.  This  was 
beautifully  illustrated  in  a  case  recently  reported  by 
Dr.  H.  G.  Wells.  In  other  cases  the  disease  is  not 
limited  to  the  epididymis,  but  has  also  involved  the 
testicle  proper  by  continuity  of  tissue.  (See  Fig.  No.  5) 
In  these  the  epididymis  presents  the  appearances  de- 
scribed above,  and  scattered  through  the  testicle  proper 
are  numerous  small  tubercular  nodules  in  all  stages  of 
development.  These  nodules  are  most  abundant  at 
the  periphery  of  the  organ,  where  they  are  very  small, 
and  on  section  present  the  homogeneous  appearance 
characteristic  of  young  tubercles.  In  the  mediastinum 
testis  they  are  apt  to  be  larger  and  caseous,  showing 


19 

that  this  was  the  part  first  affected  by  extension  from 
the  epididymis.  The  distributions  of  the  lesions  in 
the  testicle  proper  indicate  that  the  extension  took  place 
along  the  seminiferous  tubules.  Later,  in  the  course 
of  the  disease,  the  nodules  here,  as  in  the  epididymis, 
coalesce  to  form  larger  ones,  these  caseating,  becoming 
encapsulated,  or  frequently  breaking  externally.  Cal- 
careous deposit  may  take  place  either  in  the  fibrous 
capsule  or  throughout  the  broken-down  nodules.  The 
glandular  portion  is  wholly  or  in  part  destroyed.  The 
tunica  vaginalis  usually  presents  evidences  of  chronic 


\  : 


I'ig.  T. — a.   Cross  sections  of  tube  of  epididymis,     b.  Tubercle  witb 
giant   cell.      c.   Old   fibrous   tissue.      Prom   Case   11. 

inflammation,  thickening  and  adhesions  between  the 
visceral  and  parietal  layers,  or,  in  some  cases  tubercular 
lesions.  This  involvement  of  the  tunica  vaginalis  by 
the  tubercular  process  is  well  illustrated  in  Fig.  6, 
which  is  a  photograph  of  a  testicle  removed  by  Dr. 
Oswald.  In  this  case  the  entire  testicle  had  to  be  re- 
moved on  account  of  the  extensive  involvement.  An 
effusion  into  the  cavity  of  the  tunica  vaginalis  is  present 
in  most  cases,  but  is  usually  small  in  amount. 

Spermatic  Cord. — This  is  affected  in  a  considerable 
proportion  of  the  cases,  but  usually  not  throughout 
its  entire  length.     The  parts  most  apt  to  be  involved 


20 

are  either  or  both  of  the  extremities,  the  intermediate 
portion  remaining  free.  In  some  cases,  however,  the 
entire  vas  is  t hit-lamed  and  nodular  (Senn). 

The  tubercular  deposits  in  the  cord  are  usually  situ- 
ated in  the  neighborhood  of  the  vas,  the  infection 
having  taken  place  by  extension  along  the  surface  of 
its  mucous  membrane  from  the  infected  epididymis. 
All  stages  of  development  of  the  tubercular  lesions  are 
found  here  as  in  the  epididymis,  but  in  most  cases  have 
not  advanced  to  the  same  stage.  The  mucous  lining 
of  the  vas  is  greatly  thickened,  the  outer  layers  of  the 
wall  being  affected  to  a  lesser  degree.  The  connective 
tissue  surrounding  it  may  also  present  nodules  and 
caseous  areas,  but  much  of  the  thickening  is  due  to 
edema  and  inflammatory  exudate. 

Vesicular  Seminales. — The  vesiculze  seminales  come 
next  to  the  vas,  as  regards  their  frequency  of  secondary 
involvement.  While  usually  these  organs  are  involved 
only  after  the  vas  has  become  more  or  less  extensively 
diseased,  this  is  not  always  the  case.  The  process  in 
them  may  be  far  advanced  without  the  vas  being  affected 
at  all,  or  the  latter  may  present  lesions  which  have  evi- 
dently developed  at  a  later  period  than  those  in  the 
vesicles.  Later  abscess  may  form  and  the  pus  be  dis- 
charged through  the  bladder  or  rectum,  or  externally 
through  the  perineum. 

The  Prostate. — This  organ  follows  the  vesiculae  sem- 
inales in  order  of  frequency  of  involvement,  though 
some  observers  (Kocher)  state  that  it  is  affected  much 
oftener  than  i?  commonly  supposed,  the  disease  in  it 
being  overlokcd  on  account  of  the  absence  of  symptoms 
and  physical  signs  in  the  early  stages.  The  process 
here  is  the  same  as  in  other  parts,  the  deposits  going 
on  to  caseation  and  suppuration,  and  later  rupturing 
into  the  rectum,  urethra  or  externally.  In  most  cases 
the  prostatic  lesions  are  in  an  earlier  stage  of  develop- 
ment than  those  in  the  epididymis.  The  prostate  and 
seminal  vesicles  may  be  affected  unilaterally,  and  when 
this  is  the  case,  the  side  presenting  the  lesion  usually 
corresponds  to  that  of  the  diseased  epididymis.  It  is 
more  common,  however,  for  the  entire  prostate  or  both 
vesicles  to  be  affected. 

Microscopic  Appearances. — The  series  of  pathologic 
changes  which  follow  the  lodgement  of  the  bacilli  in 
the  tissues  is  the  same  as  in  tuberculous  lesions  else- 


•31 

where  in  the  body,  modified  somewhat  by  the  anatomical 
structure  of  the  organ.  The  bacilli,  having  gained  access 
to  the  circulation  by  one  of  the  channels  mentioned 
above,  lodge  in  the  walls  of  the  smaller  blood-vessels  of 
the  epididymis  and  there  produce  their  characteristic 
reaction.  (Nepveau.)  As  to  the  exact  situation  of  the 
starting-point  of  the  process,  there  is  great  difference 
of  opinion,  Malassez  and  Eeclus  locating  it  in  the  walls 
of  the  seminal  tubules;  Virchow,  Tizzoni,  and  Gaule, 
in  the  intertubular  connective  tissue;  while  Langhans, 
Curling,  Kocher,  and  others  believe  it  to  be  in  the 


Jo 


Pig.  8. — Showing  young  tubercle  between  coils  of  tube  of  epididy- 
mis,    a.  Tube  of  epididymis,     b.  Tubercle.     From  Case  11. 


interior  of  the  tubules  themselves.  Hutinel  and  Des- 
champs  found  the  primary  focus  in  the  perivascular 
spaces  in  the  cases  examined  by  them.  As  in  the 
majority  of  cases,  the  infection  probably  takes  place 
through  the  blood-current,  it  seems  reasonable  to  sup- 
pose that  the  primary  lodgment  of  the  bacilli  is  in  the 
intertubular  connective  tisue  of  the  epididymis,  and 
this  view  is  certainly  supported  by  studies  of  tubercu- 
losis in  other  organs. 

The  specific  irritation  set  up  by  the  bacilli  and  their 
products  causes,  first,  an  increased  vascularity  of  the 


22 

part,  and  then  proliferation  of  the  fixed-tissue  cells, 
ami  emigration  of  leucocytes  from  the  capillaries.  In 
this  \v;iy  nodules  of  the  so-called  tubercle  tissue  are 
produced  between  the  coils  of  the  tube  of  the  epididymis 
(Pig.  7).  widely  separating  them  Erom  each  other 
and  encroaching  upon  their  lamina.  This  tubercle 
tissue  consists  essentially  of :  1,  epithelioid  cells,  derived 
from  the  fixed  tissue  cells,  connective  tissue  and  endo- 
thelium of  the  blood-vessels  and  lymph-spaces;  2,  the 
reticulum,  in  the  meshes  of  which  the  epithelioid  cells 
lie.  This  reticulum  may  be  derived  from  the  newly 
proliferated  endothelial  cells,  or  it  may  be  the  remains 
of  the  tissues  which  previously  existed.  Later,  in 
addition  to  the  tubercle  tissue,  the  leucocytes,  which 
at  first  were  present  in  small  numbers,  become  more 
numerous,  especially  at  the  periphery  of  the  nodule. 
(Fig.  8.)  It  is  in  this  so-called  round-celled  infiltra- 
tion that  we  find  the  plasma  cells,  sometimes  in  great 
numbers  and  usually  arranged  in  groups.  These,  ac- 
cording to  different  authors,  may  be  derived  either 
from  the  lymphocytes  of  the  blood,  or  from  the  con- 
nective-tissue cells.  Their  function  at  present  is  doubt- 
ful, some  claiming  that  they  possess  phagocytic  prop- 
erties; others  that  they  have  no  such  function,  and 
are  destined  to  become  converted  into  fibrous  connective 
tissue.  Scattered  through  the  tissue,  usually  occurring 
singly  rather  than  in  groups,  are  found  the  mast  cells 
of  Ehlrich,  which  are  also  of  doubtful  origin  and  func- 
tion. The  epithelioid  cells  may  be  mononuclear  or 
polynuclear,  giant  cells  (Fig.  9),  which  latter  are 
formed  by  the  proliferation  of  the  nucleus  of  the  cell 
without  division  of  the  cell  body,  and  are  usually  found 
in  the  center  of  the  tubercle,  surrounded  by  the  mono- 
nuclear epithelioid  cells. 

When  the  individual  tubercles  have  attained  a  certain 
size,  caseous  degeneration  sets  in,  due  both  to  the  action 
of  the  toxin  and  to  the  gradual  shutting  off  of  the  blood- 
supply,  and  it  is  at  this  point  that  the  process  may  be 
arrested  by  encapsulation,  or  that  secondary  infection, 
with  destruction  of  a  part  or  whole  of  the  organ,  may 
occur.  If  encapsulation  takes  place,  the  connective- 
n-  in-  cells  which  have  proliferated  at  the  periphery  of 
the  tubercle,  or  tubercles,  gradually  contract  and  become 
converted  into  a  dense  fibrous  tissue,  in  this  wav  causing 


23 


an  arrest  of  the  process,  the  nodules  remaining  for  an 
indefinite  period  of  time. 

During  the  progress  of  the  changes  described  above,  0 
the  coils  of  the  tube  of  the  epididymis  are  encroached 
upon  and  present  a  variety  of  changes.  The  epithelium 
may  have  entirely  desquamated  at  the  site  of  involve- 
ment, the  cells  lying  loose  in  the  lumen,  which  may  be 
greatly  dilated  and  contain  pus-cells  and  granular  debris, 
the  remains  of  degenerated  cells  and  spermatozoa.  '  In 
other  sections  the  lumen  is  filled  with  caseous  material, 
which  has  probably  come  from  the  tubercles  in  the 
walls,  rather  than  from  the  interior  of  the  tube  pri- 


Fig.  9. — Giant  cell  in  center  of  Tubercle.     From  Case  11. 

marily.  The  duct  may  present  in  certain  parts  great 
dilatation  and  be  filled  with  purulent  material  and 
spermatozoa.  In  these  latter  the  epithelium  may  be 
intact  or  desquamated  in  parts. 

Tubercle  bacilli  can  usually  be  demonstrated  in  the 
sections,  especially  where  the  process  is  in  the  early 
stages.  Later,  after  caseation  has  taken  place,  they 
may  be  so  few  in  number  as  to  escape  observation,  even 
on  careful  examination. 

Beclus  has  described  a  rare  pathologic  condition  in 
tuberculosis  of  the  testicle,  in  which,  instead  of  the 
changes    described   above,   the   epididymis    presents    a 


34 

reticular  arrangement,   the  alveoli  of  which  are  tilled 
with  pus. 

Symptoms. — These  differ  materially,  as  in  tubercu- 
losis of  other  organs,  vailing  with  the  rapidity  of 
advancement  of  the  process,  the  presence  or  absence 
of  mixed  infection,  and  again  as  the  disease  is  primary 
or  secondary  in  the  testicle. 

The  symptoms  of  onset  vary  greatly  at  the  different 
periods  of  life.  In  infants  and  young  children  the 
parents'  attention  is  usually  first  called  to  the  presence 
of  a  small  nodule  in  the  epididymis,  the  child  having 
manifested  no  other  symptoms,  except  perhaps  slight 
tenderness  in  this  region. 

In  adults  the  initial  symptoms  may  be  sudden  or 
gradual  in  their  onset,  the  latter  being  much  the  more 
common  of  the  two.  When  associated  with  mixed  infec- 
tion, the  onset  is  stormy,  and  there  are  all  the  mani- 
festations of  an  acute  epididymitis,  resembling  the 
gonorrheal  form.  (Case  10.)  Abscess  formation  may 
be  rapid,  and  the  pus  find  its  way  to  the  surface  in  a 
short  time,  leaving  a  sinus  that  heals  slowly.  Instead 
of  breaking  externally,  the  burrowing  may  be  in  the 
direction  of  the  testis  proper,  and  a  portion  or  all  of 
this  organ  be  destroyed.  Rupture  into  the  cavity  of 
t\e  tunica  vaginalis  must  be  extremely  rare,  if  it  ever 
occurs. 

When  unassociated  with  mixed  infection,  the  onset 
is  slower,  and  many  of  the  patients  come  to  the  phys- 
ician for  the  first  time  because  of  the  nodule  which  they 
have  accidentally  discovered  in  the  epididymis.  They 
are  usually  unable  to  say  how  long  it  has  been  there, 
but  in  some  instances  date  its  development  from  a  slight 
injury  or  a  gonorrheal  epididymitis.  The  nodule  or  nod- 
ules are  at  first  painless  and  only  slightly  tender  on  com- 
pression ;  but  usually  after  a  short  time  the  patient 
experiences  a  dull,  aching  pain  in  the  testicle,  brought 
on  or  aggravated  by  exercise.  This  pain  may  be  referred 
to  the  testicle  or  upward  along  the  spermatic  cord, 
sometimes  even  extending  into  the  ilio-lumbar  region 
of  the  same  side.  It  is  rarely  severe,  and  may  be 
entirely  absent  when  the  patient  is  at  rest. 

A  urethral  discharge,  usually  whitish  and  mucoid  in 
character,  has  been  noted  in  a  considerable  proportion  of 
the  cases,  usually  quite  early  in  the  course  of  the  dis- 
ease.    Instead  of  being  white,   it  may  be  purulent  or 


25 

even  bloody.  Various  theories  have  been  advanced  as 
to  the  origin  of  this  discharge,  some  claiming  that  it 
is  due  to  tuberculosis  of  the  prostate,  vesiculse  seminales, 
or  the  prostatic  urethra,  while  others  believe  it  is 
caused  by  a  catarrhal  condition  of  the  posterior  urethra 
and  seminal  vesicles.  The  latter  is  probably  the  true 
explanation,  as  it  disappears  after  castration  or  epi- 
didymectomy.  Symptoms  of  vesical  irritation  are  pres- 
ent in  the  great  majority  of  cases  without  mixed  infec- 
tion, and  in  some  they  are  the  first  to  attract  the 
patient's   attention.      At    first,   there    may   be    slightly 


Pig.  10. — Globus  Minor  and  body  of  epididymis  dissected  from 
testicle  proper,  a.  Globus  Minor  and  body.  6.  Globus  Major, 
c.  Reflected  tunica  Vaginalis,     d.  Testicle  proper. 

increased  frequency  of  urination,  with  perhaps  a  little 
burning  during  the  act,  referred  to  the  base  of  the 
bladder.  As  the  case  progresses,  the  irritability  be- 
comes more  marked  until  the  patient  is  unable  to 
retain  his  urine  more  than  fifteen  or  twenty  minutes 
at  a  time,  involuntary  passage  taking  place  if  he  attempts 
to  do  so.  Later,  also,  tenesmus  develops,  and  may  be- 
come very  severe.  The  fact  that  vesical  symptoms  are 
usually  absent  in  the  cases  with  secondary  infection 
is  to  be  explained,  in  all  probability,  by  the  edema  and 
swelling  of  the  vas,  which  does  not  permit  the  irri- 


26 

t  a  ling   material    to   pass    through   it    to    the   vesicular 
seminales. 

Hemorrhage  from  the  urethra  may  occur  early  or 
late,  and  is  usually  not  profuse.  The  blood  is  passed 
with  the  urine,  and  without  obvious  cause,  in  this  latteT 
respect  differing  from  the  hemorrhage  of  renal  calculus, 
which  is  brought  on  by  severe  exercise,  such  as  horse- 
back riding,  etc.  The  source  and  cause  of  this  hemor- 
rhage are  somewhat  uncertain,  but  we  believe  it  is  due, 
as  are  the  symptoms  of  vesical  irritation,  to  the  irri- 
tating action  of  the  products  of  the  tubercular  process, 
which  are  discharged  into  the  prostatic  urethra  through 
the  vesicuke  seminales.  This  discharge  produces  a 
catarrhal  condition  of  the  mucous  membrane  in  the 
posterior  urethra  and  trigone  of  the  bladder,  with,  in 
many  cases,  erosions  and  superficial  ulcerations.  That 
the  vesical  irritation  and  hemorrhage  are  not  manifesta- 
tions of  a  tubercular  process  in  the  bladder  and  prostate, 
we  are  convinced  from  clinical  observation,  as  in  almost 
all  cases  in  which  these  symptoms  are  present,  there 
is  an  immediate  cessation  of  them  after  castration  or 
resection  of  the  epididymis,  which  could  not  possibly 
be  the  case  if  they  were  due  to  tuberculosis  of  these 
parts.  This  rapid  subsidence  of  the  symptoms  after  op- 
eration is  illustrated  in  the  majority  of  cases  here  re- 
ported, but  strikingly  so  in  one  operated  upon  10  years 
ago.  In  this  case  the  patient  was  obliged  to  urinate 
every  15  or  20  minutes  and  was  entirely  incapacitated 
for  his  duties  as  clergyman.  Unilateral  castration  was 
performed  and  vesical  symptoms  disappeared  almost  im- 
mediately. In  a  letter  received  several  days  ago  he  re- 
ports that  his  weight  is  now  260  pounds ;  there  has  never 
been  a  recurrence  of  the  disease  or  bladder  irritability, 
and  since  the  operation  he  has  worked  steadily. 

Hydrocele,  which  is  present  in  about  one-third  of  the 
cases,  may  have  been  the  first  symptom  to  attract  the 
patient's  attention.  It  is  rarely  large,  when  due  to 
tuberculosis  in  the  epididymis,  and  there  is  but  little 
difficulty  presented  in  diagnosis. 

At  varying  intervals  from  the  onset  of  the  trouble 
softening  of  the  deposit  in  the  epididymis  takes  place. 
This,  in  the  acute  cases,  may  be  a  few  weeks,  while  in 
the  more  chronic  ones  it  may  not  occur  for  months  or 
even  years  after  the  onset.  When  the  abscess  is  about 
to  rupture,  the  skin  of  the  scrotum  over  the  fluctuating 


ai 


mass  becomes  adherent  to  it,  bluish  in  color,  and  finally 
perforates  by  a  small  opening,  through  which  the 
characteristic  caseous  material  is  discharged.  There 
is  usually  no  pain  attending  this  process  and  but  little 
tenderness,  except  where  it  is  associated  with  mixed  in- 
fection, in  which  event  we  have  all  the  manifestations  of 


fi 


Fig.  11. — Showing  epididymis  freed  from  testicle  proper,  a.  Epi- 
didymis (body).  b.  Globus  Minor.  c.  Spermatic  artery  and 
veins,     d.  Tunica  Vaginalis   reflected,     e.   Testicle  proper. 

an  acute  cellulitis.  The  sinuses  formed  by  rupture  of 
the  abscess  cavity  may  be  single  or  multiple,  and  situ- 
ated in  different  parts  of  the  scrotum.  They  usually 
remain  open  indefinitely,  and  show  no  tendency  to  close 
spontaneously.    The  amount  of  discharge  is  slight. 


28 

Eernia  testis  is  rarely  seen  at  the  present  time,  prob- 
ably because  the  cases  are  operated  on  at  an  early  stage. 
It  is  consequent  upon  the  rupture  of  a  tubercular  abscess 
situated  in  the  testicle  proper,  and  consists  simply  of 
tuberculous  granulation  tissue,  which  is  extruded 
through  the  opening,  forming  a  fungus  mass  of  greater 
or  less  size. 

Constitutional  symptoms  are  present  in  the  majority 
of  cases,  though  they  differ  greatly  in  degree.  Some 
patients  present  the  typical  tubercular  appearance,  while 
others  appear  to  be  in  perfect  general  health.  In  most 
of  the  cases,  after  the  process  has  been  present  for  some 
time,  there  is  loss  of  weight  and  strength,  with  perhaps 
some  evening  temperature,  rarely  exceeding  100  F., 
and  night  sweats. 

The  sexual  desire  is  usually  unaffected,  except  in  the 
very  severe  cases,  even  though,  when  both  epididymi  are 
involved,  there  may  be  no  seminal  discharge  during  in- 
tercourse. 

Examination  of  the  patient  may  reveal  the  presence 
of  some  old  tubercular  lesions  on  other  parts  of  the 
body,  such  as  lupus  scars,  cicatrices  of  the  neck,  or  per- 
haps the  evidences  of  a  healed  osteomyelitis.  In  Case 
No.  10  of  our  series  the  diagnosis  at  first  was  somewhat 
doubtful,  because  of  the  rapid  growth  of  the  testicular 
tumor,  but  the  presence  of  a  tubercular  tendo-synovitis 
of  the  hand  cleared  up  all  doubt  as  to  its  nature. 

Rectal  examination,  for  the  purpose  of  ascertaining 
the  condition  of  the  vesiculse  seminales  and  prostate, 
should  always  be  made.  The  seminal  vesicles  are  fre- 
quently involved,  or  if  only  one  is  affected,  it  is  more 
likely  to  be  the  one  on  the  side  of  the  affected  epididy- 
mis. In  the  early  stages  the  vesicle  is  soft,  swollen, 
somewhat  painful  to  pressure,  and  can  be  outlined 
throughout  its  entire  length  by  the  examining  finger. 
Later,  nodules  develop  in  it,  and  it  presents  a  very 
irregular  shape,  hard,  with,  perhaps,  fluctuating  areas 
in  different  parts.  When  both  are  affected,  they  can  be 
plainly  felt  converging  toward  the  prostatic  urethra. 

It  is  more  difficult  to  determine  tubercular  disease 
of  the  prostate,  especially  in  its  early  stages,  because 
the  process  is  usually  situated  deep  in  the  substance  of 
the  gland.  In  the  early  stage  of  the  prostatic  disease 
the  gland  may  be  somewhat  swollen  and  tender  to  pres- 
sure, while  later,  when  the  process  is  farther  advanced. 


29 


it  may  be  nodular,  and  present  fluctuating  areas. 
Either  lateral  lobe  may  be  affected  singly,  or  if  the  en- 
tire gland  is  involved,  it  may  be  more  advanced  on  one 
side  than  on  the  other.  The  inguinal  lymph-glands  are 
rarely  involved  in  tubercular  disease  of  the  testicle. 

Uranalysis. — The  condition  of  the  urine  will  depend 
■on  the  stage  to  which  the  disease  has  advanced.  Usually 
when  the  patient  presents  himself  for  treatment  small 
quantities  of  pus  and  blood  will  be  found  in  the  cen- 
trifuged  specimen.  By  staining  the  pus  for  tubercle 
bacilli  they  can  usually  be  demonstrated,  although  al- 


Fig.  12. — Showing  entire  epididymis  free  from  testicle  proper  and 
vas  isolated.  a.  Epididymis.  b.  Vas  deferens.  c.  Spermatic 
vessels,     d.  Tunica  Vaginalis   (reflected),     e.  Testicle  proper. 


most  always  in  very  small  numbers.  It  is  of  great  im- 
portance in  searching  for  the  bacilli  to  use  special  stain- 
ing methods,  so  that  the  smegma  bacillus  will  not  be 
mistaken  for  the  tubercular  germ.  Various  processes 
for  differentiating  these  two  organisms  have  been  pro- 
posed, the  most  reliable  being  that  of  Bunge  and 
Trantenroth,  which  consists  of  extracting  the  fat  from 
the  bacilli  by  allowing  the  preparation  to  remain  for 
three  hours  in  absolute  alcohol,  then  treating  it  for 
fifteen  minutes  with  a  5  per  cent,  solution  of  chromic 


30 

acid,  and  washing  in  several  changes  ui'  water.     The 

preparation  is  then  to  be  stained  with  carbol-l'iuhsni. 
destained  in  dilute  sulphuric  or  pure  nitric  acid  for  one 
to  three  minutes,  and  further  destained  and  at  the  same 
time  counterstained,  by   immersing  in  a  concentrated 

alcoholic  solution  of  methylene  blue  for  five  minutes. 
By  this  means  the  tubercle  bacilli  retain  the  stain,  while 
the  smegma  bacilli  become  decolorized.  Soudan  iii, 
in  saturated  alcoholic  solution,  may  also  be  used  for 
differentiating  the  two. 

Complications. — The  routes  by  which  extension  of 
the  tubercular  process  takes  place  are  at  present  the 
subject  of  much  dispute,  many  authors  claiming  thai 
the  disease  exists  primarily  above  and  extends  downward 
to  the  epididymis  along  the  surface  of  the  mucous  mem- 
brane, extension,  therefore,  in  an  upward  direction  not 
taking  place.  As  stated  above,  it  is  our  opinion  that 
the  primary  focus  is  in  the  epididymis,  and  that  subse- 
quently extension  takes  place  along  the  lumen  of  the  vas 
to  the  vesicuke  seminales.  prostate,  and  in  a  few  cases 
to  the  bladder,  ureters  and  kidne3r. 

Jacobson  .-ays  that  after  the  disease  localizes  itself  in 
the  epididymis  it  may  spread  by  way  of  the  Lymphatics, 
but  this  is  a  very  rare  exception  to  the  general  rule. 
That  it  may  in  rare  cases  extend  by  the  lymphatics  is 
shown  in  Sommers'  case  (quoted  by  Senn)  of  a  man, 
aged  36  years,  who  suffered  from  tuberculosis  of  both 
testicles.  The  retroperitoneal  glands  became  involved, 
and  later  pulmonary  tuberculosis  developed.  In  this 
case  the  testes  were  primarily  affected,  the  epididymis 
remaining  free  from  disease  throughout. 

Pott's  disease  of  the  spine  has  frequently  been  ob- 
served to  follow  tuberculosis  of  the  testicle,  and  this,  as 
well  as  the  cases  of  general  miliary  tuberculosis  which 
occasionally  develop,  must  be  explained  by  dissemina- 
tion of  the  infectious  material  through  the  blood-stream. 

DIFFERENTIAL   DIAGNOSIS. 

In  acute  cases,  where  the  symptoms  come  on  sud- 
denly and  with  great  intensity,  the  diagnosis  from 
gonorrheal  epididymitis  may,  at  first,  be  difficult.  The 
principal  points  to  be  considered  are : 

1.  The  presence  of  an  active  gonorrhea,  the  discharge 
of  which  may  have  suddenly  disappeared  just  before  the 
onset  of  swelling  in  the  epididymis. 


:;i 


2.  Examination  of  opposite  epididymis,  vesiculse 
seminales  and  prostate  shows  absence  of  nodules. 

3.  Previous  history  of  patient.  In  tubercular  disease 
there  is  frequently  a  history  of  recurring  mild  attacks 
of  epididymitis,  or  enlarged  cervical  glands  in  child- 
hood, osteomyelitis,,  etc.  These  are  more  likely  to  be 
absent  in  the  gonorrheal  cases. 

4.  Occasionally  it  may  be  impossible  to  make  an 
immediate  diagnosis,  and  in  these  we  must  await  fur- 
ther developments,  which  will  occur  after  the  acute- 
swelling  has  subsided.  The  tuberculin  test  might  be 
valuable  here,  and  in  all  cases  where  a  urethral  discharge 
is  present  a  bacteriologic  examination  should  be  made. 

Syphilis. — This  disease  may  affect  either  the  testicle 
proper  or  the  epididymis,  or  both,  in  which  latter  case 
they  are  simultaneously  involved. 


Syphilis  of  the  Epididymis. 

1.  Infrequently  localized. 

2.  Diffuse  or  nodular  enlarge- 
ment, ustially  the  former. 


3.  Epididymis  not  sensitive  to 

pressure. 

4.  Almost  always  painless. 

5.  No  thickening  of  the  sper- 

matic cord. 

6.  Vesiculse   seminales  not  in- 

volved. 

7.  Usually    no    vesical    symp- 
.    toms. 

8.  Rapid  disappearance  of  le- 

sions  under   KI   and   mer- 
cury. 

9.  Frequently       evidence       of 

syphilis    elsewhere    in    the 
body. 

10.  No  tubercle  bacilli  in  the 
urine. 


Tuberculosis    of    the   Epi- 
didymis. 

1.  Frequently  localized. 

2.  Usually  nodular.     In   most 

cases  begins  in  globus 
minor,  but  may  commence 
in  globus  major. 

3.  Almost    always    some    ten- 
derness on  pressure. 

4.  Usually  slight  aching  pain 

after  exercise. 

5.  Spermatic    cord    frequently 
thickened  and  nodular. 

6.  Vesiculse  seminales  may  be 

nodular. 

7.  Almost  always  symptoms  of 

vesical  irritation  and  fre- 
quently hemorrhage. 

8.  Antisyphilitic  remedies  have 

no  effect. 

9.  No  such  evidences;  may  be 

signs  of  old  tubercular  le- 
sions in  the  lungs,  glands, 
etc. 

10.  Tubercle   bacilli   may   fre- 
quently be  demonstrated  in 


32 


Syphilis    of    Testicle   Proper. 

1.  Usually  begins  in  the  body 
of  the  testicle. 

2.  Usually  diffuse  involvement, 

rarely  circumscribed. 

3.  Sinuses  rarely  present,  and 

if    they    do    exist,    usually 
last  but  a  short  time. 

4.  Fungating  form  quite  com- 

mon. 

5.  Usually   definite  history  of 

primary      and       secondary 
manifestations. 
<3.  Yields    promptly    to    anti- 
syphilitic  treatment. 


Tuberculosis  of  7'csticlc 
Proper. 

1.  Body  of  testicle  never  pri- 

marily   affected.       Always 
secondary  to  epididymitis. 

2.  Disease   nearly   always   cir- 

cumscribed,      having      ex- 
*.  tended  from  the  hilum. 

3.  Sinuses  more  common,  and 

they  persist  indefinitely. 

4.  Rare. 

5.  No  such  history. 


6.  No    effect    from    antisyph- 
ilitic  treatment. 


Sarcoma  and  carcinoma  are  anatomically  two  dis- 
tinct and  separate  diseases  of  the  testicle.  Clinically 
and  practically,  however,  from  the  standpoint  of  diag- 
nosis and  treatment,  they  may  be  considered  as  one. 


Malignant  Disease  of  the 
Testicle. 

1.  Usually  begins  in  the  body 

of  the  testicle  as  a  hard, 
smooth  swelling,  which 
later  becomes  soft. 

2.  Growth   is  very  rapid,   ex- 

cept in  the  rare  scirrhus 
form. 

3.  May    attain    a    very    large 

size. 

4.  No  inflammatory  symptoms 

present  during  rapid 
growth. 

■5.  Veins  of  scrotum  enlarged 
and  prominent.  Skin  thin 
and  dark  colored. 

€.  Tumor  not  tender  to  pres- 
sure. 

7.  Vesical  symptoms  not 
marked. 


Tuberculosis  of  the  Testicle. 

1.  Tuberculosis  always  begins 

in     the     epididymis     as     a 
nodular  enlargement. 

2.  Growth  is  slow. 


3.  Never  attains  great  size. 

4.  Usually  some  inflammatory 

manifestations,  which  may 
be  violent,  if  mixed  infec- 
tion takes  place. 

5.  Veins   not   enlarged.     Skin, 

if  affected,  is  thickened  and 
adherent  to  the  epididymis. 

6.  Nodules  usually  tender. 

7.  Vesical     symptoms    always 

prominent. 


33 

8.  If  fungating,  the  ulcerated     8.  Ulcerating   surface   has    no 

mass  bleeds  in  a  character-  tendency  to  bleed  profusely, 

istic  way. 

9.  Cord  is  much  more  often  en-     9.  The    cord    is    nodular    and 

larged      and      swelling     is  hard, 

smooth  and  even. 

10.  Glands     above    and    below     10.  Almost  never  involved. 
Poupart's  ligament  may  be 

involved. 

11.  May  be  metastatic  tumors     11.  Sometimes  evidences  of  old 
in  lungs,  abdomen,  etc.  tubercular      lesions      else- 
where, as  lupus  scars,  cica- 
trices in  the  neck,  etc. 

12.  No  tubercle  bacilli  in  urine.    12.  Bacilli  often  present. 

Iii  fibrous  induration  of  the  epididymis,  due  to  some 
previous  acute  or  subacute  inflammation,  the  epididy- 
mis, while  hard  and  thickened,  is  not  usually  nodular, 
history  of  the  case  is  entirely  different  from  that  of  a 
tubercular  disease. 

Of  the  benign  tumors  of  the  testicle,  fibromata,  en- 
chondromata  and  osteomata  are  of  such  rare  occurrence 
that  they  need  not  be  considered  in  the  differential 
diagnosis.  Enchondroma  and  osteoma  are  sometimes 
secondary  developments  in  sarcoma,  adenoma  and 
myxoma.  Myomata  have  been  described,  but  are  very 
rare. 

Adenomata,  when  they  undergo  cystic  degeneration, 
may  have  to  be  considered  in  making  the  diagnosis. 

Hydrocele  usually  presents  no  difficulty  in  diagnosis, 
but  it  must  be  remembered  that  it  is  often  a  part  of  the 
tuberculosis  of  the  epididymis  and  testicle,  as  is  serous 
pleural  effusion  of  pulmonary  tuberculosis. 

Prognosis. — In  tuberculosis  of  the  testicle  the  prog- 
nosis depends  upon:  1,  the  age  of  the  patient;  2, 
whether  the  infection  is  simple  or  of  a  mixed  character ; 

3,  the    location    of    the    primary    focus    of    infection; 

4,  whether  or  not  other  portions  of  the  genito-urinary 
tract  or  more  distant  parts  of  the  body  are  involved. 

The  prognosis  in  children  in  localized  disease  of  the 
epididymis,  or  even  where  it  has  extended  into  the 
testicle  proper,  with  or  without  mixed  infection,  is 
usually  favorable.  Encapsulation  takes  place  in  the 
majority  of  cases  without  pus  infection,  and  a  portion 
of  the  testis  is  preserved.  Even  where  secondary  infec- 
tion has  taken  place  and  the  abscess  cavity  discharged 


34 

ixternally,  we  ran  always  hope  for  the  preservation  of 

at  least  a  small  portion  of  the  glandular  struct  inc. 

This  tendency  in  children  to  encapsulation  and  limi- 
tation of  the  process  is  the  same  as  that  observed  in 
tuberculosis  of  other  organs  in  them,  with  the  exceptions 
of  tubercular  meningitis  and,  to  a  lesser  degree,  oste- 
omyelitis. 

In  adult  cases  many  complications  are  apt  to  develop, 
and  it  is  on  these  that  the  prognosis  will  in  large  part 
•depend.  The  most  important  are :  1,  abscess  formation 
with  resulting  sinuses  of  the  scrotum;  2,  involvement  of 
the  seminal  vesicles  and  prostate;  3,  tuberculosis  of  the 
bladder  (rare).  In  addition  to  these  we  may  have  foci 
develop  in  any  other  part  of  the  body,  and  even  general 
miliary  tuberculosis  has  been  known  to  follow  a  primary 
lesion  in  the  epididymis.  Whether  the  affection  of  the 
seminal  vesicles  or  prostate  precedes  or  follows  the 
testicular  disease  or  not.  the  clinical  fact  remains  the 
same,  the  removal  of  the  testicle  or  epididymis  causes, 
in  a  large  percentage  of  the  cases,  a  complete  subsidence 
•of  the  vesical  and  prostatic  symptoms,  and  a  healing 
•of  the  tubercular  process  in  these  parts.  From  the 
symptoms  presented  by  some  of  the  patients  who  have 
come  under  our  care,  it  seemed  certain  that  the  tubercu- 
losis had  extended  to  the  mucosa  of  the  bladder,  but 
on  removal  of  the  diseased  testicle  or  epididymis  they 
•entirely  subsided.  While  the  prognosis  is  favora- 
ble in  prostatic  and  seminal  vesicle  involvement,  it  is 
distinctly  unfavorable  when  the  disease  has  extended  to 
the  bladder.  In  these  cases  it  very  frequently  further 
■extends  to  the  ureters  and  kidneys,  and  the  patient 
soon  succumbs  to  renal  or  general  miliary  tuberculosis. 

If  the  epididymis,  which  is  primarily  affected,  be  re- 
moved early,  it  is  probable  that  the  other  testicle  will 
not  become  involved.  Should  it,  however,  become  im- 
plicated, the  urinary  and  vesical  symptoms  will  recur 
and  bacilli  will  again  be  found  m  the  urine. 

As  regards  life,  Jacobson  says:  "It  is  to  be  looked 
upon  as,  if  left  to  itself,  an  ultimately  fatal  disorder." 
This,  we  believe,  is  an  exaggeration,  and  is  by  no  means 
invariably  the  case,  as  in  some  the  process  becomes  en- 
capsulated and  remains  so  throughout  life.  Even  where 
both  testicles  are  involved  and  discharging  sinuses  pres- 
ent, the  general  health  may  remain  good  indefinitely,  as 
in  a  case  reported  by  E.  Albert  of  ten  years'  standing. 


35 

Tubercle  bacilli  can,  in  some  cases,  be  demonstrated 
in  the  semen,  and  in  this  way  infection  may  be  trans- 
mitted to  the  female.  It  is  interesting  to  observe  that 
Jackh  found  tubercle  bacilli  in  the  semen  from  healthy 
testicles  in  cases  of  pulmonary  tuberculosis. 

Treatment. — This  may  be  divided  into  1,  palliative; 
2,  radical. 

Under  palliative  treatment  we  recognize,  a,  rest;  b, 
support  to  tEe  diseased  organ;  c,  constitutional  treat- 
ment; d,  the  various  injection  methods,  with  iodoform, 
chlorid  of  zinc.  etc. ;  e.  the  method  recently  advocated 
by  Mauclaire,  which  consists  in  excising  a  section  of  the 
spermatic  cord  between  two  ligatures. 

Radical  treatment  may  be,  a,  orchiectomy ;  b,  epididy- 
mectomy,  either  partial  or  complete,  with  excision  of  a 
part  or  whole  of  the  vas  deferens;  c,  incision  and 
drainage,  with  or  without  curettage  or  cauterization 
with  the  thermocautery,  chlorid  of  zinc  solution,  etc. 

The  disease  in  children,  as  before  stated,  has  a  ten- 
dency to  rapid  encapsulation,  circumscribing  the  process 
to  a  local  caseous  nodule  in  the  globus  major  or  minor 
or,  in  some  cases,  even  extending  into  the  mediastinum 
testis,  but  occasionally  there  is  complete  destruction  of 
the  epididymis  and  glandular  portion  of  the  testicle 
proper,  nothing  remaining  after  a  time  but  an  abscess 
cavity.  In  children,  too,  there  is  a  much  greater  likeli- 
hood of  mixed  infection  than  in  adults,  and  it  is  this 
which  usually  causes  the  rapid  destruction  mentioned 
above.  Felizet  years  ago  made  the  statement  that  in 
acute  genital  tuberculosis  of  children  castration  is  the 
only  operation  to  be  considered,  and  this  statement  has 
never  been  contradicted.  (Longuet.)  If  suppuration,  \ 
with  destruction  of  the  testicle,  has  already  taken  place 
when  first  seen  by  the  surgeon,  incision  and  drainage 
may  be  the  only  operation  necessary.  Early  incision  and 
drainage,  without  curettage,  is  urgently  indicated 
in  children  where  secondary  infection  is  present  to  pre- 
vent the  destruction  of  the  glandular  portion,  which 
may  take  place  without  it.  The  rule  is,  in  infants  and  .  » 
children,  that  no  radical  operation  is  indicated,  and  the  \ 
treatment  of  these  patients  should  be  the  same  as  for 
tuberculosis  of  the  lymphatic  glands,  namely,  syrup  of 
the  iodid  of  iron,  cod-liver  oil  and  calcium  lactophos- 
phate.     Epididymectomy  is  practically  never  called  for. 

The  course  of  the  disease  is  so  varied  in  adults,  from 


36 

an  acute  inflammatory  process  to  a  chronic  indolent, 
almost  painless  one.  thai  the  palliative  treatment  of  each 
case  will  depend  on  the  peculiarities  presented.  Rest 
and  support  are  of  the  greatest  importance,  as  is  also 
the  constitutional  treatment,  which  is  indicated  in  all 
cases  of  tuberculosis,  wherever  situated.  This  consists 
of  an  abundance  of  fresh  air  and  sunshine,  moderate 
exercise,  plenty  of  fats  in  the  food  and  cod-liver  oil. 
Changes  of  climate  and  scene,  on  which  so  many  authors 
have  laid  stress,  are  probably  of  no  great  importance. 

If  there  is  no  mixed  infection  and  no  fistula?  present, 
iodoform  and  zinc  injections  are  absolutely  contrain- 
dicated,  and  really  have  no  place  in  the  treatment  of  this 
disease.  They  are  uncertain,  and  while,  in  a  few  cases. 
they  seem  to  have  been  followed  by  good  results,  the 
procedure   is  not   rational. 

The  method  of  treatment  advocated  by  Mauclaire  in 
his  recent,  paper  has  not  as  yet  been  tested  in  a  suf- 
ficient number  of  cases  to  say  whether  or  not  it  will 
have  a  place  in  the  treatment  of  tuberculosis  of  the 
epididymis  and  testicle.  It  is  certainly  not  radical,  and 
does  not  seem  to  be  rational  if,  as  he  says,  the  testicle 
will  be  nourished  by  blood-vessels  from  the  tunica 
vaginalis,  after  ligation  of  the  spermatic  cord.  He,  how- 
ever, has  noted  disappearance  of  the  nodules  in  several 
of  his  cases,  and  in  almost  all  of  them  a  subsidence  of 
the  vesical  symptoms,  and  healing  of  the  lesions  in  the 
vesiculas  seminales  and  prostate. 

Orchiectomy  was  in  vogue  for  many  years  prior  to 
1895,  and  is  still  advocated  by  many  able  men,  as 
Koenig,  Kocher,  Terrilon,  Richet  and  Senn,  though 
most  of  them  are  opposed  to  double  castration  except 
in  very  exceptional  instances.  It  would  be  the  opera- 
tion of  election,  because  of  its  ease  of  performance  and 
the  rapid  healing  of  the  parts  which  usually  follows, 
were  it  not  for  the  unnecessary  mutilation,  the  influence 
on  general  metabolism,  the  mental  effect,  and  for  the 
fact  that  patients  will  not  consent  to  it  until  the 
1 1  incase  is  very  far  advanced.  As  the  glandular  por- 
tion of  the  testis  is  practically  never  primarily  in- 
volved, and  very  rarely  seriously  secondarily  affected, 
there  is  no  good  surgical  basis  for  its  removal.  The 
claim,  which  has  always  been  made  by  the  advocates  of 
castration,  that  the  operation  is  more  radical  than  epi- 
didymectomy,  is  not  proved  by  the  results  of  opera- 


37 

tions,  and  it  is  for  the  purpose  of  controverting  this 
idea  that  this  paper  has  been  prepared  and  these  cases 
cited.  In  38  cases  reported  by  Badenheuer  in  which 
castration  was  performed  for  tuberculosis  of  the  testicle 
there  was  recurrence  of  the  disease  in  the  other  organ  28 
times.  Bazy.  Eoutier  and  Mauclaire  have  noted  the 
same  recurrence  in  the  other  testicle  in  many  cases. 
These  statistics  form  the  strongest  argument  against 
castration  that  can  possibly  be  brought  forward,  be- 
cause, as  the  disease  so  frequently  develops  on  the 
other  side,  a  double  castration  will  be  inevitable,  if  it 
be  true,  as  these  authors  claim,  that  it  is  the  only  radical 
operation. 

Another  great  objection  to  the  performance  of  cas- 
tration is  the  profound  mental  effect  which  is  induced 
in  many  patients,  not  only  where  both  organs  have  been 
removed,  but  sometimes  by  the  removal  of  one.  Pujol, 
in  2  cases  of  unilateral  castration,  observed  melan- 
cholia following  the  operation,  and  Fualds,  in  3  similar 
cases,  noted  the  development  later  of  grave  mental  symp- 
toms. These  mental  changes  may  in  part  be  due  to 
psychical  impression,  or  they  may  be  ascribed  to  absence 
of  the  internal  secretion  of  the  testicle,  but  whatever 
their  cause,  the  fact  remains  that  they  develop  in  a  cer- 
tain and  rather  large  percentage  of  the  cases.  The  sec- 
ondary secretion  and  its  importance  to  normal  metab- 
olism were  considered  in  the  physiology.  Tillaux,  in 
1896,  says :  "I  believe  that  the  testicular  substance  has 
an  important  influence  on  the  general  health.  The 
secretion  is  resorbed  in  part  by  the  system  and  con- 
tributes to  the  vigor  of  the  organism."  Audebal  also 
condemns  castration  for  the  same  reason. 

We  do  not  consider  that  a  surgeon  is  justified  in  re- 
moving a  testicle  for  tuberculosis  where  the  epididymis, 
or  only  a  part  of  the  testicle  proper,  is  involved.  Even 
when  the  seminal  vesicles  are  diseased,  it  does  not  sup- 
ply an  additional  indication  for  castration,  nor  is  the 
effect  on  the  vesical  symptoms  more  rapid  or  more  pro- 
nounced and  permanent  when  castration  is  performed 
than  when  the  epididymis  alone  is  ablated.  After 
orchiectomy,  in  many  cases,  there  is  a  gradual  and  often 
ultimately  complete  subsidence  of  the  sexual  desire, 
which  is  not  the  case  after  epididjmiectomy. 

Curettage  and  Drainage. — This  is  of  no  more  effect  in 
the  treatment  of  tuberculosis  of  the  testicle  and  epididy- 


38 

V^  mis  than  it  is  in  the  knee-joint  or  other  tissue.  It  is 
followed  by  prolonged  suppuration,  further  extension  of 
the  disease  and  final  destruction  of  the  organ.  It  has 
many  disadvantages,  and  no  advantages  over  the  more 
radical  epididymectomy.  Where  the  testicle  is  much 
swollen  and  infiltrated,  so  that  it  is  impossible  to  de- 
termine the  exact  condition  of  affairs,  it  is  justifiable 
to  incise  and  drain  the  infiltrated  tissues,  and  later,  after 
the  acute  infection  has  subsided  and  the  exact  extent  of 
the  disease  ascertained,  do  an  epididymectomy.  Lon- 
guet  advocates,  in  cases  where  the  tubercular  foci  are 
softened  and  liquefied,  incision  into  the  abscess  cavi- 
ties, curettage  of  their  walls  and  cauterization  with  the 
thermocautery  or  chlorid  of  zinc.  His  results  in  some 
cases  were  excellent.  After  curettage  the  wound  may 
be  packed  with  iodoform  gauze  and  allowed  to  granulate, 
or  it  may  be  closed  with  sutures. 

Excision  of  foci  in  the  testical  proper  was  advocated 
by  Deville  in  1852,  and  about  the  same  time  by  Syme 
and  Malgaigne  (quoted  by  Longuet).  Reclus  has  per- 
formed the  same  operation  with  perfect  success.  S. 
Duplay,  in  1897,  recommended  dissecting  out  tubercular 
foci  in  the  testicle  and  closing  the  defect  left  by  sutur- 
ing with  catgut. 

Epididymectomy. — L.  Longuet,  in  his  recent  excel- 
lent paper,  treated  very  extensively  the  subject  of  con- 
servative operations  for  tuberculosis  of  the  testicle,  both 
from  the  historical  and  technical  points  of  view.  The 
first  epididymectomy  on  record  was  performed  by  Jar- 
javay  in  1850,  upon  a  patient  20  years  of  age,  with 
tuberculosis  of  the  right  epididymis.  He  resected  the 
epididymis  Aug.  7, 1850,  and  swabbed  the  wound  out  with 
tincture  of  iodin.  As  mentioned  before,  Syme  and  Mal- 
gaigne, for  some  time  previous  to  Jarjavay's  operation,, 
had  been  teaching  that  in  fungus  and  carcinomatous 
testicular  affections  not  involving  the  whole  organ  the' 
diseased  portion  only  should  be  removed,  and  Deville, 
in  1852,  saved  a  testicle  which  was  prolapsed  through 
an  ulcerating  scrotum  by  resecting  the  diseased  foci. 
In  these  earlier  operations,  however,  it  was  not  the- 
I  epididymis  that  was  removed,  but  rather  portions  of  the 
testicle  proper  in  which  the  disease  had  become  localized. 

Typical  total  epididymectomy  was  probably  first  per- 
formed by  Bardenheuer  in  1880,  and  in  1887  he  reported 
12  successful  cases.    Tuffier  in  1883,  Villeneuve  in  1889,. 


39 

Duplay  in  1890,  Humbert  in  1891  and  Lejars  in  1893,. 
reported  cases  and  advocated  the  conservative  operations. 
Dr.  Herman  Mynter,  of  New  York,  in  1893,  reported  2 
cases  in  which  he  had  performed  epididymectomy  one 
and  two  years  previously.  Both  patients  had  remained 
perfectly  well  up  to  the  time  of  the  report,  and  there 
was  no  prospect  of  recurrence  in  either.  Guyon.  1892, 
condemned  castration  where  the  epididymis  only  was 
involved.  Longuet,  during  the  period  from  1895  to 
1898,  had  performed  30  typical  and  atypical  epididy- 
mectomies  with  most  excellent  results.  Humbert,  in 
1897,  published  the  reports  of  15  resections,  with  good 
results  in  the  majority  of  cases.  Reclus  has  done  a 
number  of  successful  resections,  but  thinks  the  operation 
indicated  only  when  the  disease  is  distinctly  localized 
in  the  epididymis. 

Indications  for  the  Operation. — Epididymectomy 
should  be  the  operation  of  election  in  every  case  of  tuber- 
culosis of  the  epididymis,  single  or  double,  except  under 
the  following  conditions : 

1.  Where  there  are  extensive  tubercular  lesions  else- 
where, which  will  shortly  terminate  the  patient's  life. 

2.  Where  the  disease  has  extended  to  and  destroyed 
the  greater  part  or  all  of  the  testis  proper.  Here  cas- 
tration should  be  done. 

3.  Where  the  scrotum  is  riddled  with  discharging 
sinuses.  The  indication  is  usually  here  also  for  castra- 
tion. In  every  other  ease  a  resection,  typical  or  atypical, 
should  be  done  for  the  following  reasons : 

1.  Because  it  is  radical  and  removes  all  the  diseased 
tissue. 

2.  It  does  not  remove  the  healthy  glandular  portion 
of  the  testicle,  the  internal  secretion  being  thus  pre- 
served. 

3.  Patients  will  consent  to  an  early  removal  of  the 
epididymis,  thereby  avoiding  the  disastrous  results  of 
further  infection  of  the  genito-urinary  tract. 

4.  It  has  the  same  beneficial  effect  on  the  vesical 
symptoms  as  has  orchiectomy. 

5.  Sexual  desire  and  potency,  even  to  emissions,  are 
retained ;   power  of  procreation,  however,  is  lost. 

6.  It  has  no  ill  effects  on  the  general  metabolism,  nor 
does  the  patient  suffer  from  the  mental  distress  and  mel- 
ancholia mentioned  above. 


•10 

7.  It  is  easy  of  performance  and  entirely  devoid  of 
danger. 

8.  The  period  of  convalescence  is  short,  and  the  good 
results  are  permanent. 

The  principal  objections  which  have  been  brought 
against  the  operation  are: 

1.  That  it  is  not  radical,  as  the  rete  testis  is  involved 
in  every  case,  even  where  it  appears  normal  macroscopi- 
cally.     (Koenig,  Fink,  Diirr.) 

2.  That  atrophy  of  the  testicle  follows  the  operation. 

3.  That,  as  the  patient  will  be  sterile  after  either  epi- 
•didymectomy  or  orchiectomy,  it  is  unwise  to  risk  the 
possibility  of  leaving  in  infected  tissue. 

With  regard  to  the  first  objection,  e.  g.,  that  the  opera- 
tion is  not  radical,  we  have  only  to  say  that  while  theo- 
retically this  may  be  true,  practically  it  is  not.  Where 
the  rete  testis  is  seriously  involved,  to  such  an  extent 
that  it  will  give  rise  to  trouble  later,  it  will  always  be 
possible  to  determine  it  macroscopically  at  the  time  of 
the  operation,  and  excise  the  affected  portion  with  the 
epididymis.  If  this  is  done,  recurrence  need  not  be 
feared,  but  even  supposing  it  does  take  place  in  a  small 
proportion  of  the  cases,  a  localized  focus  in  the  rete  can 
be  excised  at  a  subsequent  operation  and  no  harm  result 
from  the  delay,  for  the  reason  that  as  the  vas  is  absent, 
extension  upward  can  not  take  place.  As  a  precaution- 
ary measure,  in  order  to  avoid  leaving  infected  tissue, 
some  operators — Lejars,  Koenig,  Poncet,  Delbet  and 
Andre — have  recommended  an  exploratory  incision  into 
the  testicle,  the  subsequent  operation,  castration  or  epi- 
didymectomy,  to  be  determined  by  the  condition  of  af- 
fairs in  the  rete.  In  the  cases  which  have  come  under 
our  care,  this  has  never  been  necessary,  it  always  being 
possible  to  detect  deposits  in  the  rete  at  the  time  of  re- 
moval of  the  epididymis. 

The  symptoms  of  vesical  irritation  subside,  after  re- 
section of  the  epididymis,  just  as  promptly  and  com- 
pletely as  after  castration,  and  the  healing  of  secondary 
deposits  in  the  prostate  and  seminal  vesicles  takes,  place 
just  as  rapidly.  Even  where  the  tubercular  process  in 
these  latter  situations  is  far  advanced,  arrest,  by  cicatri- 
zation and  encapsulation,  is  the  rule  after  epididymec- 
tomy.  For  this  reason  it  is  never  necessary  to  remove 
these  organs. 

The  second  objection,  that  atrophy  of  the  testicle  fol- 


41 

lows  removal  of  the  epididymis,  is  not  founded  on  fact,. 
for  numerous  observations  and  experiments  have  shown 
conclusively  that  when  the  operation  is  correctly  per- 
formed and  the  spermatic  vessels  not  interfered  with, 
atrophy  does  not  take  place.  (T.  Dimetresco.)  The 
testes  not  only  retain  their  normal  size,  but  also  their 
natural  firmness  and  sensitiveness.  (Longuet.)  Mau- 
claire.  in  one  case  upon  which  unilateral  epididymec- 
tomy  had  been  performed  observed  that  the  testis  on  the 
side  of  operation  retained  its  normal  size,  while  the  op- 
posite one  became  hypertrophied.  In  Cases  4  and  5  of 
our  series  the  testicle  presented  some  atrophy,  which 
must  be  accounted  for  by  a  slight  injury  to  the  vessels 
at  the  time  of  operation;  a  considerable  portion  of  the 
organ,  however,  remains  in  each  case. 

The  third  objection  is  hardly  worth  considering,  as 
the  importance  of  the  internal  secretion  is  not  recog- 
nized by  those  who  make  it.  After  epididymectomy  the 
patient  is  sterile,  but  not  impotent,  while  after  castra- 
tion he  is  both.  Reynier  objects  to  the  conservative 
operations  because  he  thinks  that  permanent  sinuses 
are  often  left.  This  is  certainly  not  true  if  the  opera- 
tion is  properly  done.  The  sinuses  which  are  occasion- 
ally formed  quickly  close. 

The  operation  of  epididymectomy  is  extremely  simple 
and  easy  of  performance,  if  the  operator  will  first  take 
the  trouble  to  experiment  on  the  cadaver.  It  amounts 
simply  to  an  anatomical  dissection,  very  little  cutting 
being  necessary,  except  in  dividing*  the  vasa  efferentia 
where  they  enter  the  globus  major. 

The  steps  of  the  operation  illustrated  by  Figs.  11,  1& 
and  13  are  as  follows: 

1.  Incision  into  the  sac  of  the  tunica  vaginalis,  just 
external  and  parallel  to  the  epididymis. 

2.  Dissection  of  epididymis  from  testis  proper,  com- 
mencing below  at  globus  minor  and  passing  upward  to 
mediastinum  testis.  From  here  one  must  proceed 
slowly  and  carefully  so  as  not  to  injure  the  spermatic 
artery  and  veins,  closely  hugging  the  epididymis  and 
separating  it  from  the  testis  proper  and  spermatic  ves- 
sels. Blunt  dissection  should  be  used  when  possible, 
cutting  only  when  necessary.  If  a  focus  is  discovered 
in  the  mediastinum  it  is  to  be  excised  in  a  wedge-shaped 
piece  and  the  defect  closed  with  catgut  sutures. 

3.  When  the  globus  major  is  free,  the  vas  is  to  be  iso- 


42 

lated  from  the  other  structures  of  the  cord  upward,  as 
far  as  the  internal  ring,  where  it  is  to  be  clasped  on  both 
sides  of  its  circumference  with  hemostatic  forceps,  di- 
vided and  the  lumen  of  the  proximal  end  cauterized  with 
95  per  cent,  carbolic  acid  in  the  end  of  a  needle.  The 
needle  is  to  be  worked  upward  in  the  lumen  for  one- 
half  inch  and  the  mucous  membrane  thoroughly  cau- 
terized. 

1.  When  cauterization  is  complete  the  vas  is  ligated 
with  chromicized  catgut,  one-quarter  of  an  inch  from  its 
end,  so  as  to  prevent  infectious  material  from  passing 
backward  through  it  into  the  tissues.  This  step  is  con- 
sidered of  great  importance  as  previous  to  the  use  of  the 
ligature  it  was  not  uncommon  to  have  induration  and 
occasionally  suppuration  develop  near  the  stump  of  the 
vas.  The  tunica  albuginea  is  to  be  sutured  with  catgut, 
if  it  has  been  opened. 

5.  The  testicle  is  now  replaced  in  the  scrotal  sac,  and 
the  external  wound  closed  either  with  a  buried  subcu- 
taneous suture  of  catgut,  or  interrupted  sutures  of  silk- 
worm gut,  leaving  a  small  iodoform  gauze  drain  in  the 
lower  angle  for  forty-eight  hours. 

6.  After  forty-eight  hours  the  gauze  drain  is  removed 
and  provisional  sutures,,  put  in  at  the  time  of  the  opera- 
tion, are  tied. 

REPORT  OF  CASES. 

Case  1. — Mr.  E.  J.  B.,  aged  22  years.  Occupation,  factory- 
man.  Unmarried.  Admitted  to  Alexian  Brothers  Hospital, 
Sept.  9,   1894. 

Present  Illness. — Six  months  ago  patient  first  noticed  some 
"chafing  of  skin"  on  the  left  side  of  scrotum,  and  a  varicocele 
on  the  same  side,  which  had  been  present  for  several  months, 
became  larger  and  somewhat  painful.  Shortly  afterward  a 
small  papule  developed  on  the  irritated  skin  and  this  was 
opened  by  patient.  Cheesy  material  was  discharged,  and  a 
small  sinus,  which  would  not  close,  was  formed.  There  was 
at  no  time  any  marked  swelling  of  testicle  and  patient  suf- 
fered but  little  pain.  Has  had  no  urinary  symptoms  of  any 
kind.  Has  lost  considerably  in  weight  (10  pounds).  No 
coui^h. 

Previous  History. — Chorea  several  times  in  childhood.  Be- 
fore onset  of  present  trouble  patient  worked  in  a  shop  where 
much  heavy  lifting  was  a  part  of  his  daily  labor.  No  history 
of  venereal  infection.     No  direct  injury  to  testicles. 

Family  History. — No  tuberculosis  in   any  members. 

Examination    of    Patient. — Medium    stature.      Nourishment 


43 

fair.  Heart,  lungs  and  abdomen  negative.  (Jenilalia.—lj  ft 
epididymis  thickened,  hard,  nodular  and  slightly  tender  to 
compression.  Testicle  proper,  normal.  A  small  sinus  leading 
down  into  nodular  epididymis  is  present  in  left  side  of  scrotum. 
Right  testicle  and  epididymis  normal. 

Operation.— Sept.  10,  1894.  Operator,  Dr.  J.  B.  Murphy, 
assisted  by  Dr.  E.  H.  Lee.  Incision  into  left  tunica  vaginalis 
and  dissection  of  epididymis  from  testicle  proper,  leaving  the 
spermatic  vessels  undisturbed.  Vas  severed  from  other  struc- 
tures of  cord,  ligated  and  amputated  at  internal  ring.  Testi- 
cle proper  replaced  in  sac  of  tunica  vaginalis  and  skin  wound 
•closed  with  silkworm  gut  suture,  leaving  small  gauze  drain  in 
lower  angle.  The  night  after  operation  some  secondary  hemor- 
rhage took  place  and  house  surgeon  applied  a  ligature  to  the 
bleeding  vessel.  After  this  the  wound  healed  without  further 
trouble,  except  at  the  upper  angle,  where  a  small  sinus  persisted. 
Sinus  remained  open  for  two  years,  when  ligature  was  dis- 
charged and  it  closed.  General  health  improved  much  after 
operation  and  he  regained  the  flesh  which  he  had  lost.  For 
ultimate  results  see  notes  under  Case  5. 

Case  2. — Mr.  M.  Z.,  aged  22  years;  occupation,  watch- 
maker; unmarried.  Admitted  to  Mercy  Hospital  December 
14,  1895. 

Present  Illness:  For  four  years  previous  to  last  April,  when 
the  organ  was  removed,  patient  had  had  repeated  attacks  of 
pain  and  swelling  in  the  right  testicle.  Eight  weeks  ago  the 
left  testicle  began  to  swell  and  a  permanent  nodular  enlarge- 
ment developed.  This  has  been  accompanied  by  considerable 
dull,  aching  pain,  and  some  tenderness  in  the  mass.  Urina- 
tion has  been  frequent  and  painful.  Family  history  negative 
as  regards  tuberculosis. 

Examination  of  Patient:  Right  testicle  absent.  In  the  left 
side  of  the  scrotum  is  a  firm  nodular  mass  situated  pos- 
teriorly, and  having  in  front  of  it  the  testicle  proper,  which  is 
apparently  normal. 

Operation,  Dec.  16,  1895;  Operator,  Dr.  J.  B.  Murphy,  as- 
sisted by  Dr.  E.  H.  Lee.  Incision  into  left  tunica  vaginalis; 
dissection  of  nodular  epididymis  from  the  testicle  proper;  liga- 
tion and  amputation  of  the  vas  high  up,  and  cauterization  of 
its  lumen  with  95  per  cent,  carbolic  acid.  Testicle  replaced  in 
the  scrotum  and  the  wound  closed  with  silkworm  gut  sutures, 
a  gauze  drain  being  left  in  the  lower  angle.  Cavity  of  the 
tunica  vaginalis  on  the  right  side  opened  and  a  hollow  oval 
ball  of  silver,  the  size  and  shape  of  a  normal  testicle,  intro- 
duced and  the  wound  closed.  Convalescence  was  uneventful, 
and  patient  was  discharged  cured  Dec.  25,  1895.  In  a  letter 
received  from  him  May  8,  1900,  the  following  particulars  as 
to  his  present  state  of  health  are  given:  His  general  health  is 
excellent.     He  has  gained  ten  pounds  since  the  operation,  now 


•14 

weighing  ISO.  He  has  no  vesical  irritation,  and  has  passed  no 
blood  or  pus  in  the  urine.  There  has  been  no  return  of  the 
disease  since  the  operation,  though  patient  states  that  occa- 
sionally he  has  some  slight  pain  in  the  testicle,  which  may  be 
attributed  to  the  silver  ball  in  the  right  side.  There  has  been 
no  atrophy  of  the  left  testicle  proper.  He  has  had  no  cough. 
fever  or  sweats.  He  has  been  married  for  several  months  and 
states  that  the  sexual  desire  is  normal,  there  being  some  dis- 
charge during  intercourse.  No  nocturnal  emissions  since 
operation. 

(ask  :!. — M.  S.  K.  V.,  aged  30  years;  married;  occupation, 
electroplater.  Admitted  to  Cook  County  Hospital,  service  of 
Dr.  F.  "S.  Hartman,  Dec.  1G,  1895. 

Present  Illness:  About  nine  years  ago  right  testicle  was 
swollen  for  several  weeks.  Swelling  gradually  subsided,  leav- 
ing a  small,  hard,  painful  nodule  in  the  lower  and  posterior 
portion  of  organ,  which  has  persisted  until  the  present  time. 
Frequent  urination  has  been  complained  of  iately,  and  he  has 
had  to  void  his  urine  every  fifteen  or  twenty  minutes  with- 
out, however,  having  any  pain  during  its  passage.  During  the 
past  two  or  three  weeks  he  has  had  numerous  hemorrhages  from 
urethra. 

Previous  History.  Patient  claims  he  was  never  sick  before, 
and  positively  denies  any  venereal  infection.  Family  history 
entirely  negative  as  regards  tuberculosis. 

Examination  of  Patient:  Well-nourished  man;  heart,  lungs 
and  abdomen  negative.  Right  testicle  is  enlarged,  and  a  firm 
nodular  mass  can  be  felt  involving  the  lower  and  posterior  por- 
tion of  the  organ.  In  the  left  testicle  there  is  a  hard  nodule 
occupying  the  upper  and  posterior  portion. 

JJranalysis :  Dark  color,  neutral  reaction.  Specific  gravity 
1018.  Albumin;  no  sugar.  Microscopic  examination,  red 
blood-cells  and  pus  in  moderate  amount. 

Operation,  Dec.  17,  1895.  Operator,  Dr.  J.  B.  Murphy,  as- 
sisted by  Drs.  Besley  and  Champlin.  Incision  over  nodular 
mass  in  upper  and  posterior  part  of  left  testicle;  diseased 
tissue  well  exposed,  caught  with  forceps,  and  dissected  from 
body  of  the  testicle,  the  latter  being  apparently  normal.  Iodo- 
form gauze  drain  inserted  and  the  wound  closed  with  silk- 
worm gut  sutures.  Exactly  similar  operation  performed  on 
right  side.  Convalescence  was  uneventful  and  patient  was 
discharged  cured  Dec.  31.  1895. 

Examination  of  patient  June  27.  1896,  showed  that  there 
had  been  no  return  of  the  testicular  disease,  and  the  blood 
had  disappeared  from  the  urine.  He  had  gained  fourteen 
pounds  since  the  operation,  and  sexual  desire  was  same  as  be- 
fore. About  one  year  after  operation,  patient  suddenly  de- 
veloped urinary  suppression,  which  continued  for  twenty-four 
hours.      Several    days    later    he    had    a    similar    attack    lasting 


45 

sixty  hours.  At  this  time  the  left  kidney  became  enlarged  and 
soon  afterward,  the  right.  He  died  of  the  renal  complication, 
probably  tuberculosis  of  both  kidneys,  early  in  February,  1897. 
There  was  no  recurrence  of  the  trouble  in  the  testicles,  and  the 
lungs  were  unail'ected  throughout.  Tubercle  bacilli  were  found 
in  the  urine  toward  the  close  of  the  disease.  While  the  ulti- 
mate result  in  this  case  was  bad,  the  success  of  the  operation, 
as  regards  the  disease  in  the  testicles  and  the  relief  of  bladder 
symptoms,  was  demonstrated,  as  there  was  no  sign  of  local  re- 
currence, and  no  return  of  urethral  hemorrhages  up  to  the  time 
of  his  death. 

Case  4. — Mr.  A.  D.  B.,  aged  38  years;  occupation,  driver. 
Admitted  to  Alexian  Brothers'  Hospital  May  6,  1896.  Pres- 
ent illness  dates  from  three  and  a  half  or  four  years  ago,  at 
which  time  patient  had  what  he  calls  "eczema  of  the  scrotum." 
About  two  years  ago  urination  began  to  be  more  frequent  than 
normal,  and  he  suffered  from  some  burning  pain  at  the  base  of 
the  bladder  toward  the  end  of  micturition.  A  short  time  after 
this  he  passed  some  blood  and  pus  from  the  urethra.  One 
year  ago  a  perineal  cystotomy  was  performed,  and  at  ths 
same  time  some  operation  on  the  testicles,  the  nature  of  which 
is  unknown  to  the  patient.  After  operation  the  urinary 
fistula  remained  open  for  three  or  four  months,  when  it  closed 
completely.  Since  closure  of  fistula  he  has  been  unable  to  hold 
his  urine  more  than  one  and  one-half  hours,  involuntary  pas- 
sage taking  place  after  this  time.  He  says  that  at  the  time 
of  operation  right  testicle  was  discharging  pus,  but  that  soon 
after  it  the  sinus  closed.  For  the  past  one  and  one-half  years 
left  testicle  has  been  gradually  increasing  in  size,  and  has  been 
the  seat  of  considerable  pain.  At  the  present  time  he  is 
obliged  to  urinate  every  hour  at  least.  He  often  has  pain  at 
the  base  of  the  b!  adder  and  along  the  urethra.  Several  weeks 
ago  a  small  ulcer  developed  on  the  glans  penis,  followed  after 
about  two  weeks  by  a  similar  one  on  the  prepuce.  These  are 
still  present.  The  general  health  is  good.  Bowels  constipated. 
Patient  says  he  was  never  sick  before.  Family  history  nega- 
tive as  regards  tuberculosis. 

Examination  of  Patient:  Both  epididymi  nodular  and  hard. 
Testicles  proper  show  no  signs  of  involvement.  The  inguinal 
glands  on  both  sides  very  slightly  enlarged.  The  prepuce 
presents  on  its  inner  surface  a  large  shallow  ulceration,  which 
extends  a  short  distance  over  the  glans  penis.  Temperature 
on  admission  ranged  from  normal  to  100.3  F. 

Uranalysis  on  Admission:  Straw-colored,  cloudy,  acid  reac- 
tion, specifc  gravity  1018,  albumin  present  in  considerable 
quantities,  no  sugar.  Microscopic  examination  showed  pus 
cells,  red  blood-cells,  a  few  granular  and  epithelial  casts. 

Operation,  May  8,  1896.  Patient  circumcised  for  removal 
of  preputial  ulcer.     Operation  May   15,   1896.     Operator,   Dr. 


4t> 

J.  B.  Murphy,  assisted  by  Dr.  Oswald.  Incision  into  cavitj 
of  right  tunica  vaginalis,  testicle  and  epididymis  well  exposed,. 
and  the  latter  dissected  from  the  former,  beginning  below  and 
passing  upward.  Vas  was  amputated  high  up  and  lumen  cau- 
terized. Testicle  proper  replaced  in  sac,  and  external  wound, 
closed  by  means  of  silkworm  sutures,  leaving  a  small  gauze 
drain  in  lower  angle.  Similar  operation  performed  on  the 
left  side.  Examination  of  epididymi  showed  both  to  contain, 
typical  caseous  nodules.  Patient  was  discharged  from  hos- 
pital June  4,  189G,  the  incision  on  the  left  side  having  closed, 
by  primary  union.  On  the  right  side  there  was  a  small  sinus- 
at  the  lower  angle  of  the  wound,  which  was  discharging  a 
slight  amount  of  purulent  material.  Uranalysis  June  1  showed 
the  same  findings  as  on  admission,  except  that  the  urine  was 
clearer  and  contained  less  blood  and  pus.  On  the  day  of  dis- 
charge from  hospital  a  few  pleuritic  friction  sounds  were  heard: 
in  the  right  side  of  the  chest. 

Examination  of  patient  July  11,  1900:  General  health  ex- 
cellent; patient  now  weighs  150  pounds,  which  is  more  than 
he  ever  weighed  before.  Has  no  cough ;  appetite  good ;  no 
symptoms  referable  to  the  genital  organs,  except  some  itching 
of  the  scrotum.  Vesical  irritation,  which  was  such  a  marked! 
symptom  before  the  operation,  disappeared  almost  entirely 
within  a  month  or  six  weeks  after  it  was  performed,  and  has- 
never  returned  in  anything  like  the  same  degree.  Occasionally 
he  is  obliged  to  urinate  more  frequently  than  normal,  and. 
usually  has  to  get  up  two  or  three  times  during  the  night. 
Has  no  pain  during  urination  and  never  passes  blood.  Sexual 
desire  is  the  same  as  before  onset  of  trouble,  and  the  sensation' 
attending  intercourse  is  also  the  same,  though  he  has  no  dis- 
charge of  seminal  fluid.  It  was  neglected  in  the  history  to 
mention  that  for  about  one  and  a  half  years  before  the  first 
operation  there  had  been  no  seminal  discharge  during  coitus. 

Examination  of  the  heart,  lungs  and  abdomen  negative. 
Genitalia:  The  right  testicle  proper  is  of  normal  size  and; 
consistency,  and  there  is  absolutely  no  sign  of  recurrence  of 
the  disease.  The  left  testicle  is  very  much  atrophied,  not 
being  larger  than  the  end  of  the  middle  finger.  It  is  hard,  but 
not  at  all  tender,  and  there  is  no  evidence  of  any  recurrence 
of  the  tubercular  trouble.  Rectal  examination  shows  the- 
prostate  and   seminal   vesicles  to  be  free  from   disease. 

Uranalysis  July  11,  1900.  Clear,  yellow,  acid  reaction,  no> 
albumin,  no  sugar.     Microscope  showed  no  pus,  blood  or  casts.. 

Case  5. —  (See  Case  1).  Mr.  E.  J.  B.,  aged  24  years.  Oc- 
cupation, factoryman.  Unmarried.  Admitted  to  Alexias 
Brothers'   Hospital   Aug.    17,    1896. 

Present  Illness. — Left  epididymis  was  removed  for  tuber- 
cular disease  Sept.  10,  1894.  Small  sinus  persisted  in  wound 
after  operation  and  closed  only  a  short  time  ago.     Health  has- 


4-7 

been  good  until  about  one  month  ago,  when  the  right  testicle 
suddenly  became  enlarged,  tender  and  painful.  He  has  lost 
some  flesh,  but  has  had  no  cough,  fever  or  sweats.  No  urinary 
symptoms  have  been  present,  either  during  this  or  the  previous 
attack.     Previous  and  family  histories  given  under  Case  1. 

Examination. — Man  of  medium  stature.  Nourishment  fair. 
Heart,  lungs  and  abdomen,  negative. 

Genitalia. — Cicatrix  of  former  operation  present  on  left  side 
of  scrotum.  No  recurrence  of  disease  here,  and  testicle  is  of 
normal  size  and  consistency.  Right  side  of  scrotum  swollen. 
Right  epididymis  enlarged,  hard,  nodular,  and  very  tender. 
Testicle  proper  not  involved,  so  far  as  examination  shows. 

Operation. — Aug.  18,  1896.  Operator,  Dr.  J.  B.  Murphy. 
Assistant,  Dr.  E.  H.  Lee.  Epididymectomy  performed — ex- 
actly similar  to  that  done  on  left  side.  Drain  removed  after 
36  hours.  Wound  healed  by  primary  union  and  patient  was 
discharged  from  hospital  cured  Sept.   1,   1896. 

Examination  of  patient,  April  7,  1900.  Has  gained  thirty 
pounds  since  operation.  Feels  perfectly  well.  Has  no  coughr 
fever  or  sweats.  No  urinary  symptoms.  Sexual  desire  and 
sensation  are  the  same  as  before  onset  of  trouble,  and  patient 
says  that  seminal  discharge  is  of  the  sime  quantity.  Pa- 
tient always  supports  testicles  in  a  suspensory.  If  suspen- 
sory is  not  used,  left  testicle  swells  and  becomes  tender.  Nc- 
pain  or  tenderness  when  supported. 

Examination:  Both  testicles  present  in  scrotum  and  of  nor- 
mal consistency.  No  nodules  present  in  either.  Above  left 
testis  is  a  small  firm  band  about  three-quarters  of  an  inch  in 
length,  not  nodular,  but  slightly  tender  to  compression.  No 
hydrocele.  Patient  says  the  testicles  are  somewhat  smaller 
than  before  operation,  and  they  apparently  are  slightly  atro- 
phied. Rectal  examination  shows  in  each  seminal  vesicle  a 
small,  very  hard  and  painless  nodule.  The  tubercular  process 
has  here  been  arrested  and  encapsulated.  Discharge  during 
intercourse,  clear,  looks  like  mucus;  no  spermatozoa. 

Case  6. — Mr.  G.  L.,  aged  37  years;  occupation,  carpenter. 
Admitted  to  Alexian  Brothers'  Hospital  Sept.  21,  1897. 

Present  Illness:  About  one  year  ago  patient  began  to  cough 
and  lose  flesh.  Since  then  he  has  coughed  continuously,  ex- 
pectoration being  at  times  quite  profuse,  and  occasionally 
bloody.  Loss  of  flesh  has  been  marked.  For  some  time  past 
he  has  had  afternoon  fever,  night  sweats,  loss  of  appetite  and 
diarrhea.  Three  years  ago  he  developed  an  empyema,  which 
was  opened  and  drained  by  Dr.  Murphy.  The  empyema  sinus 
is  still  discharging  pus.  Four  months  ago  patient  noticed  a 
small  nodule  in  the  right  testicle  at  its  posterior  and  lower 
portion.  This  has  gradually  increased  in  *\zc.  but  lias  caused 
no  pain  or  other  symptoms  referable  to  it.  Complains  of 
increased   frequency  of  urination. 


IS 

Previous  History:  No  points  of  interest  except  those  given 
above. 

Examination  of  patient  shows  physical  si<;ns  of  the  con- 
ditions recorded  in  the  history.  The  nodule  in  the  globus 
minor  i^  about  the  size  of  a  hickory-nut.  The  testicle  proper 
is   apparently   not   involved. 

Operation  Sept.  23,  1*!»7.  Operator,  Dr.  J.  B.  Murphy, 
assisted  by  Dr.  Moran.  Incision  through  the  scrotal  coverings 
down  to  the  epididymis.  Epididymis  picked  up  with  forceps 
ami  dissected  from  testicle  proper,  beginning  below  and  pass- 
ing upward,  the  spermatic  vessels  being  left  intact.  Cord 
ligated  high  up  and  its  lumen  cauterized  with  95  per  cent. 
carbolic  acid.  Externa]  wound  closed  after  first  replacing  tes- 
ticle in  scrotum.  Small  gauze  drain  left  in  lower  angle  of 
wound  for  twenty-four  hours.  Convalescence  after  operation 
was  uneventful,  and  patient  was  discharged  from  the  hospital 
cured,.  SO  far  as  his  testicular  trouble  was  concerned,  Nov. 
15,   1897. 

This  patient  later  developed  a  tuberculosis  of  the  spine,  and 
died  from  a  genera]  miliary  infection  some  months  after  the 
operation.  No  recurrence  of  symptoms  referable  to  the  genito- 
urinary  (treans. 

Case  7. — Mr.  W.  C. ;  nativity,  Ireland.  Age,  38  years; 
married;  occupation,  laborer.  Admitted  to  Cook  County 
Hospital   Oct.   6,    1S97. 

Present  Illness:  About  seven  months  ago  patient  first  no- 
ticed swelling  in  the  left  side  of  the  scrotum,  which  swelling 
had  appeared  quite  suddenly  and  attained  a  somewhat  larger 
size  than  at  present  in  the  course  of  a  few  days.  Its  appear- 
ance was  accompanied  by  sharp,  shooting  pains.  The  swelling 
remained  stationary  for  five  or  six  weeks,  when  it  partially 
subsided.  The  pains  decreased  with  the  reduction  in  size  of 
the  testicle.  About  five  weeks  before  admission  to  hospital  a 
.similar  swelling  developed  in  the  right  side  of  the  scrotum, 
this  running  a  course  resembling  the  above.  He  now  com- 
plains of  some  pain  in  the  right  testicle. 

Previous  History:  Denies  syphilis  and  gonorrhea.  Has 
two  children,  oldest  18  and  youngest  2  years  of  age.  Family 
history    entirely   negative   as    regards   tuberculosis. 

Examination:      General    nourishment   good.      Scrotum    pre- 

iits  on  the  right  side  an  ovoid  mass,  about  3  by  6  cm.  in  size, 
situated  posterior  to  the  body  of  the  testicle,  which  is  appar- 
ently uninvolved.  This  ovoid  mass  is  composed  of  several  hard 
nodules.  The  spermatic  cord  is  negative.  On  the  left  side 
the  epididymis  answers  to  the  same  description  as  on  the 
right,  but  here  the  tunica  vaginalis  is  distended  with  fluid. 
Rectal  examination  shows  the  prostate  and  vesiculse  seminales 
to  be  normal.     Left  spermatic  cord  normal. 


49 

Operation  Oct.  29,  1897.  Operator,  Dr.  J.  15.  Murphy, 
assisted  by  Drs.  Simpson  and  Morf.  Incision  into  scrotal  sac 
on  each  side  down  to  the  tunica  vaginalis.  Hydrocele  on  right 
side  evacuated.  Epididymis  on  both  sides  now  removed  by 
dissecting  each  from  its  testicle  proper,  carefully  avoiding  the 
spermatic  arteries  and  veins.  Testes  replaced  in  scrotum, 
hemorrhage  controlled  and  external  wound  closed  -with  silk- 
worm gut  sutures;  gauze  drainage  in  each  lower  angle.  Pa- 
tient was  discharged  cured  Nov.  12,  1897. 

Unfortunately  we  have  been  unable  to  locate  the  patient 
since  his  discharge  from  the  hospital,  so  can  not  report  as 
to  final  outcome  of  the  operation. 

Case  8. — Mr.  W.  L.  M.,  aged  35  years;  occupation,  clerk. 
Admitted  to  Mercy  Hospital,  July  18,  1898. 

Present  illness  began  about  one  month  ago  with  sudden 
painful  swelling  of  the  right  testicle,  the  pain  being  quite 
severe  and  aggravated  by  patient  being  on  his  feet.  He  has 
had  almost  constant  headache  since  the  onset.  Appetite  is 
good ;  has  no  night  sweats  or  fever.  Since  onset  of  trouble 
he  has  lost  considerably  in  weight;  bowels  are  constipated. 
Patient  complains  of  frequent  urination,  it  being  necessary 
for  him  to  get  up  several  times  every  night  to  void  urine. 

Previous  History:  At  the  age  of  13  years  he  had  enlarged 
cervical  glands,  which  disappeared  under  treatment.  He  has 
also  had  "scarlet  fever"  and  "cystitis."     No  specific  history. 

Family  History:  One  aunt  died  of  miliary  tuberculosis. 

Examination  of  patient  negative,  except  as  regards  sexual 
glands.  On  posterior  surface  of  the  right  testicle  there  is  a 
hard  nodular  mass,  slightly  tender  to  pressure.  The  testicle 
proper  is  apparently  normal.  A  small  amount  of  fluid  is  pres- 
ent in  the  cavity  of  the  tunica  vaginalis;    cord  not  involved. 

Uranalysis  on  Admission:  Quantity  in  twenty-four,  hours, 
1200  c.c. :  specific  gravity,  1011;  reaction,  acid;  color,  yel- 
low, cloudy.  No  albumin,  no  sugar.  Microscopic  examination, 
small  amount  of  pus,  no  casts. 

Operation,  June  20,  1898.  Operator,  Dr.  J.  B.  Murphy, 
assisted  by  Drs.  Bick  and  Daly.  Incision  on  right  side  of 
scrotum  down  to  epididymis  and  into  sac  of  tunica  vaginalis. 
This  incision  was  extended  upward  to  the  external  inguinal 
ring.  The  nodular  epididymis  was  dissected  from  the  testicle 
proper,  beginning  below  and  passing  upward,  leaving  the  tes- 
ticle and  spermatic  A'essels  intact.  The  vas  was  ligated  and 
amputated  high  up,  and  the  lumen  of  the  stump  cauterized 
with  a  red-hot  needle.  A  few  catgut  sutures  were  introduced 
into  the  tunica  albuginea  to  check  oozing,  and  the  testicle 
proper  then  replaced  in  the  scrotum.  The  fascia  was  sutured 
over  the  cord  with  buried  catgut  and  the  skin  wound  closed 
by  means  of  a  subcutaneous  suture  of  fine  catgut.  Collodion 
dressing. 


50 

The  patient  made  a  perfect  recovery  and  was  discharged 
. aired  Aug.  6,   L898.     Urinalysis  on  the  day  of  discharge  from 

hospital  showed  the  following:  Slightly  cloudy;  reaction, 
acid;  specific  gravity,  1012;  no  albumin;  no  sugar.  Micro- 
scopic examination,  very  small   amount  of  pus. 

(For  ultimate  result  see  under  Case  No.  9.) 

Case  9.— Mr.  W.  L.  M.,  aged  35  years.  (See  Case  No.  8.) 
Admitted  to  Mercy  Hospital  Sept.  30,  1898. 

Present  Illness:  Last  July,  about  two  months  ago,  patient 
underwent  an  operation  for  the  removal  of  the  right  epididy- 
mis. Shortly  after  operation  left  testicle  became  swollen, 
slightly  tender  and  painful,  and  this  condition  has  persisted, 
gradually  becoming  more  severe,  until  the  present  time.  He 
still    complains   of   frequent   urination. 

Examination  shows  nodular  swelling  of  the  left  epididymis, 
adherent  to  the  surrounding  structures,  very  hard  and  slightly 
tender  to  compression.  There  is  no  sign  of  recurrence  of 
trouble  on  the  right  side.     Chest  and  abdomen  negative. 

CJranalysis,  Oct.  1,  1898,  yellow,  slightty  cloudy,  reaction 
acid,  specific  gravity  1015,  no  albumin,  no  sugar.  Micro- 
scopic examination,  small   quantity  of  pus;     no  casts. 

Operation  Oct.  1,  1898.  Operator,  Dr.  J.  B.  Murphy,  as- 
sisted by  Drs.  Rogers,  Baccus  and  Daly.  Incision  one  and  a 
half  inches  long  parallel  to  raphe,  near  the  bottom  of  the 
scrotum;  small  amount  of  fluid  escaped.  Testicle  drawn  out 
and  epididymis  dissected  off,  leaving  the  vessels  passing  to 
the  testicle  proper  intact;  vas  ligated,  amputated  and  lumen 
cauterized.  Testicle  returned  to  scrotum  and  skin  wound 
closed  by  means  of  a  buried  suture  of  silkworm  gut.  Small 
iodoform  gauze  drain  left  in  lower  angle  of  wound.  Unevent- 
ful convalescence  after  operation.  Patient  discharged  as 
cured  Oct.  15,  1898. 

Uranalysis,  Oct.  3,  1898,  quantity  in  twenty-four  hours, 
1250  c.c,  pale  yellow,  slightly  turbid,  reaction  neutral;  specific 
gravity,  1012;    no  albumin,  no  sugar. 

Microscopic  examination:  Numbers  of  epithelial  cells  and  a 
very  few  pus  cells. 

Examination  of  patient  Nov.  9,  1899.  General  health  ex- 
cellent. No  recurrence  of  tubercular  trouble  in  either  testicle, 
both  being  apparently  normal.  No  atrophy  has  taken  place. 
Patient  now  has  no  vesical  irritation. 

Examination  March  25,  1900.  Patient  feels  perfectly  well; 
has  gained  fifteen  pounds  since  last  operation,  now  weighing 
145.  The  sexual  desire  is  the  same  as  before  the  onset  of  the 
disease,  and  the  sensation  attending  intercourse  is  unchanged. 
The  seminal  emission  is  less  than  normal,  and  patient  now  has 
no  nocturnal  emissions.  The  vesical  irritation  has  entirely  dis- 
appeared. 


51 

Case  10. — Mr.  S.  R.  A.,  aged  47  years;  married.  Admitted 
to   Mercy   Hospital    Sept.    30,    1898. 

Present  Illness:  Several  months  ago  patient  first  noticed  a 
small  nodule,  slightly  painful  and  tender  to  pressure,  on 
palmar  aspect  of  right  index  finger.  This  steadily  enlarged 
and  some  swelling  developed  along  the  entire  length  of  the 
finger,  extending  into  the  palm.  Several  weeks  after  swelling 
was  first  noticed  patient  received  a  slight  traumatism  to  the 
left  testicle.  Almost  immediately  afterward  testicle  became 
swollen  and  the  epididymis  gradually  developed  the  hard 
nodular  condition  which  is  now  present.  Testicle  is  only 
slightly  painful  and  tender  under  compression.  Patient  com- 
plains of  some  increased  frequency  in  urination,  and  the 
urine  is  cloudy.  He  has  no  cough  and  the  general  health  is 
good.     No  tuberculosis  in  family. 

Examination  of  the  Patient:  Large  stature;  well  nourished; 
heart,  lungs  and  abdomen  are  negative.  Index  finger  of  right 
hand  swollen  along  its  entire  palmar  aspect,  the  swelling 
•extending  into  the  palm.  It  is  only  slightly  tender  to  pressure, 
the  skin  over  it  is  not  reddened,  and  along  the  course  of  the 
tendon  several  small  nodules  can  be  felt.  Function  is  much 
impaired.  Left  epididymis  is  thickened,  hard,  nodular  and 
adherent  to  the  surrounding  tissues.  The  spermatic  cord  is 
apparently  not  involved. 

Uranalysis,  Oct.  1,  1898.  Quantity  in  twenty-four  hours, 
1200  c.c. ;  reaction  acid,  specific  gravity,  1014;  color,  yellow; 
cloudy,  trace  of  albumin,  no  sugar.  A  few  granular  casts  and 
pus  cells  were  found  under  the  microscope. 

Operation  Oct.  1,  1898.  Operator,  Dr.  J.  B.  Murphy,  as- 
sisted by  Drs.   Rogers   and  Daly. 

1.  Finger.  Esmarch  on  wrist.  Incision  on  palmar  surface 
of  finger  along  its  entire  length  down  to  tendon;  numerous 
rice  bodies  escaped.  Fungus  granulations  dissected  out, 
hemorrhage  controlled  and  wound  closed  with  buried  silkworm 
gut  suture.     Collodion  dressing. 

2.  Testicle.  Incision  one  and  a  half  inches  long  near  the 
bottom  of  the  scrotum  on  the  left  side,  into  the  cavity  of  the 
tunica  vaginalis;  small  amount  of  hydrocele  fluid  escaped; 
testicle  drawn  out  and  diseased  epididymis  dissected  from  it, 
the  dissection  beginning  below  and  proceeding  upward.  The 
spermatic  artery  and  veins  were  left  intact;  the  vas  ligated 
and  amputated  high  up  and  its  lumen  cauterized  with  95  per 
cent,  carbolic  acid.  One  or  two  fine  catgut  sutures  were  used 
to  draw  together  the  edges  of  the  abraded  surface,  left  by  the 
removal  of  the  globus  major.  Testicle  now  returned  into  the 
scrotum  and  the  wound  closed  by  means  of  buried  catgut 
suture,  a  small  gauze  drain  being  left  in  the  lower  angle  of  the 
wound. 


Uninterrupted  convalescence  followed  the  operation,  and 
patient  was  discharged  cured  Oct.  10,  1898. 

(See  Case  No.  11  for  result.) 

Case  11. — Mr.  S.  R.  A.  (see  Case  No.  10),  aged  49  years. 
Admitted   to  Mercy  Hospital   Feb.    13,   1900. 

Present  Illness:  Since  Oct.  1898,  when  patient  underwent 
operation  for  the  removal  of  the  left  epididymis,  his  health  has 
been  good.  Five  or  six  months  ago  some  soreness  developed 
in  right  epididymis,  and  a  small  hard  nodule  became  palpable. 
There  has  been  no  pain  in  the  testicle  except  on  pressure.  He 
complains  of  frequent  urination,  the  act  being  accompanied 
by  some  pain  at  the  base  of  the  bladder.  General  health  at 
present    is   good. 

Family  history  and  previous  history  given  under  Case 
No.   10.  ' 

Examination  of  the  Patient:  Nourishment  good;  lungs, 
heart  and  abdomen  negative.  Cicatrix  on  palmar  aspect  of 
index  finger  of  right  hand  present;  no  recurrence  of  trouble 
lure.  Left  epididymis  absent,  and  the  wound  left  by  former 
epididymectomy  now  scarcely  noticeable.  No  atrophy  of  left 
testicle  and  no  sign  of  recurrence  of  tubercular  trouble.  The 
right  epididymis  is  hard,  nodular  and  slightly  tender  to 
pressure,  the  process  being  confined  quite  closely  to  the  globus 
major.  The  vas  is  apparently  uninvolved.  The  right  seminal 
vesicle  is  slightly  thickened,  while  the  left  is  apparently 
normal. 

Uranalysis  Feb.  17,  1900.  Color,  light  yellow,  slightly 
cloudy;  acid  reaction;  specific  gravity,  1015;  urea,  1.5;  al- 
bumin,  trace;     no   sugar. 

Microscopic  examination:  A  few  hyaline  and  granular  casts 
found.  Pus  cells  numerous.  Tubercle  bacilli  found  in  the 
centrifuged  specimen. 

Operation  Feb.  14.  1900.  Operator,  Dr.  J.  B.  Murphy,  assisted 
by  Drs.  Lcmke  and  Fggert.  Incision  two  inches  long  into 
cavity  of  tunica  vaginalis  over  nodular  epididymis,  just  to  the 
right  of  it.  Testicle  brought  out  of  wound;  tunica  vaginalis 
incised  at  upper  border  of  testes,  and  dissected  from  epididy- 
mis laterally.  Epididymis  now  dissected  from  the  testicle 
proper,  leaving  the  nutrient  vessels  of  the  latter  intact;  vas 
clamped  as  high  as  possible,  amputated  and  lumen  cauterized 
with  05  per  cent,  carbolic  acid.  Abraded  surface  left  by  re- 
moval of  the  epididymis  now  covered  by  flaps  of  tunica 
vaginalis  and  testicle  returned  into  the  scrotum.  Small  gntizo 
drain  introduced  into  lower  angle  and  the  external  wound 
closed  with  silkworm  gut  sutures.  The  day  after  the  opera- 
tion irritability  of  the  bladder  had  almost  entirely  subsided, 
and  has  not  since  returned.  Convalescence  was  uneventful, 
and    patient    left    hospital    March    3,    1900. 


53 


Several  later  examinations  of  the  urine  show  a  small  amount 
of  albumin  to  persist,  with  a  few  hyaline  and  granular  casts. 
In  the  centrifuged  specimen  pus  cells  are  still  found,  though  in 
smaller  numbers  than  before  operation.  Tubercle  bacilli  have 
also  been  demonstrated  on  several  occasions  since  the  last 
operation. 

Examination  of  patient  June  20,  1900:  General  health  ex- 
cellent; has  gained  fourteen  pounds  since  the  last  operation; 
appetite  is  good.  There  are  no  signs  of  recurrence  of  the 
tubercular  trouble  in  either  testicle.  Vesical  irritability  not 
now  present,  although  occasionally  he  is  obliged  to  urinate 
somewhat  more  frequently  than  normal.  No  pain  on  urination 
and  no  blood  passed.  Rectal  examination  shows  in  each  semfi- 
nal  vesicle  a  small',  very  hard  nodule,  which  is  only  slightlv 
tender  to  pressure.  The  foci  in  the  seminal  vesicles  have  evi- 
dently become  encapsulated,  as  there  are  now  no  tubercle 
bacilli  present  in  the  urine.  We  believe  that  the  seminal 
vesicles  were  the  source  of  the  bacilli  which  persisted  so  long 
after  the  last  operation. 

Case  12. — Mr.  P.  McC,  aged  30  years;  married;  occupa- 
tion moulder.  Admitted  to  Alexian  Brothers  Hospital  March 
11,  1900. 

Present  Illness:  Patient  has  a  double  hydrocele,  each  side 
being  as  large  as  a  goose  Qgg-  Scrotum  has  gradually  in- 
creased in  size  since  November,  1899.  Patient  complains  of 
pain  in  lumbar  region  and  scrotum ;    also  of  great  weakness. 

Previous  History:  Diseases  of  childhood;  specific  urethritis 
five  years  ago.  Initial  lesion  of  syphilis  ten  years  ago.  In- 
guinal adenitis  in  1894.     Operation  for  hernia  in  1899. 

Family  History:    Negative  as  regards  tuberculosis. 

Examination  of  Patient:  Heart  and  lungs  negative; 
cicatrices  of  hernial  operation  in  both  inguinal  regions. 

Genitalia:  Scrotum  very  much  enlarged,  due  to  double 
hydrocele.  Testicles  situated  below  and  behind  the  fluid  sacs. 
Both  testicles  are  apparently  somewhat  enlarged,  and  epi- 
didymi  enlarged  and  nodular,  especially  in  the  region  of  the 
globus  major. 

Uranalysis:  The  urine  contains  some  pus,  and  the  centri- 
fuged  specimen  shows   tubercle  bacilli. 

Operation  March  12,  1900.  Operator,  Dr.  J.  B.  Murphy, 
assisted  by  Drs.  Lee  and  Hess.  Two  incisions,  one  on  each 
side  of  the  median  line  of  scrotum.  Hydroceles  exposed,  sacs 
opened  and  fluid  evacuated.  Testicles  drawn  out  and  inspected ; 
both  epididymi  nodular  and  thickened,  the  tubercular  de- 
posits extending  for  a  short  distance  on  to  the  tunica  albugi- 
hea  of  the  testicle  proper.  Both  hydrocele  sacs  dissected  out 
and  removed;  both  epididymi  and  adjacent  tunica  albuginea 
removed  by  dissecting  from  the  testicle  proper,  beginning  be- 


54 

low  and  passing  upward.  Leaving  the  vessels  of  the  testicle 
proper  intact.  Cords  isolated,  and  the  vas  on  each  side 
clamped  and  ligated  high  up.  Lumina  cauterized  with  95  per 
nut.  carbolic  acid.  Cut  edges  ul  tunica  albuginea  approxi- 
mated and  sutured.  A  small  gauze  drain  inserted  at  the 
lower  angle  of  each  scrotal  incision  and  external  wounds 
closed. 

Microscopic  examination  of  epididymi  showed  large  amount 
of  old  fibrous  connective  tissue,  with  a  few  scattered  tubercles 
containing  giant  cells. 

Convalescence  uneventful,  and  patient  discharged  from  the 
hospital    March    15,    1000. 

We  have  been  unable  to  trace  this  patient  since  his  dis- 
charge from  the  hospital,  so  can  not  report  on  his  present  con- 
dition. 

Case  13. — Mr.  J.  M.,  aged  37  years;  German;  married. 
Admitted  to  Alexias  Brothers'  .Hospital.  April   1,  1900. 

Present  illness  dates  from  two  months  ago,  when  patient 
was  taken  sick  with  high  fever,  pains  all  over  the  body  and 
other  symptoms  of  an  acute  infectious  disease.  He  had  no 
cough  or  any  localizing  symptoms  at  first,  but  two  days  after 
the  onset  the  left  testicle  suddenly  became  swollen,  and  he 
experienced  some  pain  in  the  left  inguinal  region.  Testicle 
continued  to  enlarge  for  a  number  of  days,  but  was  not  tender, 
and  was  the  seat  of  no  pain.  He  did  not  complain  of  frequent 
urination,  and  never  passed  blood  in  the  urine.  The  bowels 
have  been  constipated,  and  he  has  some  pain  in  the  rectum 
during   defecation. 

Previous  History:  Patient  states  that  twelve  years  ago  he 
"strained  himself,"  and  soon  after  had  some  swelling  and  pain 
in  the  right  testicle.  The  symptoms  subsided  after  a  few 
days,  but  a  nodule  remained  in  the  upper  and  posterior  por- 
tion. This  nodule  enlarged  slowly  and  two  years  ago  a  sur- 
geon incised  the  swelling  and  allowed  "water"  to  escape.  No 
tissue  was  removed  at  that  time,  and  the  nodule  is  still  pres- 
ent. One  year  ago  patient  suffered  from  very  frequent  and 
painful  urinations,  and  on  two  occasions  passed  some  blood 
in  the  urine.  At  that  time  he  had  fever,  and  during  the  six 
months  that  the  trouble  persisted  lost  twenty  or  twenty-five 
pounds  in  weight.  He  bad  no  symptoms  directly  referable 
to  the  testicles  at  that  time.  After  about  six  months  the 
symptoms  disappeared  and  he  was  in  good  health  until  the 
onset  of  the  present  trouble,  two  months  ago.  He  denies  ab- 
solutely ever  having  had  any  venereal  disease.  No  history  of 
injury.    He  is  married  and  the  father  of  a  number  of  children. 

Family  history  presents  no  points  of  interest.  No  tubercu- 
losis in  any  of  the  members  so  far  as  can  be  ascertained. 

Examination  of  Patient:  Medium  stature;  nourishment 
poor;   temperature,   98.6   F. 


55 

Heart  and  lungs  negative.  Abdomen,  some  slight  diffuse 
tenderness.  The  edge  of  the  liver  is  palpable  three-quarters 
of  an  inch  below  the  costal  arch.  Kidneys  are  not  palpable. 
There  is  quite  marked  tenderness  in  the  right  lower  quadrant 
of  the  abdomen. 

Genitalia:  In  right  epididymis  there  is  a  hard,  round  and 
slightly  tender  nodule  in  the  globus  major.  The  vas  deferens 
passes  somewhat  more  anteriorly  than  normal,  and  the  testicle 
is  rotated  so  that  the  epididymis  lies  to  the  inner  side  rather 
than  posteriorly.  In  the  left  epididymis  there  are  numerous 
hard  nodules  massed  together.  The  cord  is  thickened  and  ten- 
der at  its  lower  portion. 

Rectal  Examination:  Both  seminal  vesicles  are  enlarged, 
the  right  soft,  the  left  nodular  and  tender.  Urine,  yellow, 
turbid,  reaction  acid.  Trace  of  albumin.  The  microscope  re- 
veals pus  cells  and  a  few  red  cells.     No  tubercle  bacilli  found. 

Operation  April  12,  1900.  Operator,  Dr.  J.  B.  Murphy. 
Incision  over  the  left  epididymis  and  cord,  epididymis  dissected 
from  testicle  proper,  leaving  the  spermatic  vessels  intact. 
The  cord  was  dissected  from  the  surrounding  tissues  up  to  the 
internal  ring,  where  it  was  ligated,  amputated,  and  the  lumen 
cauterized  with  95  per  cent,  carbolic  acid.  Testicle  proper 
replaced  in  scrotum,  and  wound  closed  with  subcutaneous 
suture,  leaving  a  small  gauze  drain  in  the  lower  angle.  Right 
epididymis  not  operated  upon,  as  the  process  had  evidently 
been  arrested  by  encapsulation.  Convalescence  was  uneventful, 
and  the  patient  discharged  about  ten  days  after  operation. 

Since  discharge  from  hospital,  pain  in  the  left  groin  has 
persisted.  Left  testicle  is  tender,  as  is  also  the  stump  of  the 
amputated  cord.  Occasionally  he  is  obliged  to  pass  the  urine 
oftener  than  normal,  but  has  passed  no  blood.  Complains  of 
some  pain  in  the  left  ilio-lumbar  region,  which  is  aggravated 
by  stooping  forward.  Defecation  is  still  painful.  He  states 
that  his  weight  is  the  same  as  before  operation.  Has  no  chills, 
fever  or  sweats.  Has  some  burning  pain  in  the  urethra  dur- 
ing urination.  There  is  a  small  discharging  sinus  in  the 
cicatrix  on  the  left  side  of  the  scrotum,  and  the  tissues  pos- 
terior to  the  testicle  and  at  the  stump  of  the  cord  present 
some  inflammatory  infiltration.  Both  seminal  vesicles  are  in 
the  same  condition  as  they  were  when  patient  was  admitted  to 
the  hospital.     Heart,  lungs  and  abdomen  negative. 

In  a  letter  written  August  25,  1900,  patient  states  that  he 
is  at  work  and  feeling  better,  but  still  has  considerable  pain 
in  the  left  side  and  back.  It  was  not  possible  for  him  to  come 
to  the  city  for  examination. 

I  desire  to  express  my  appreciation  of  the  valuable 
services  rendered  by  Dr.  J.  M.  jSTeff  in  the  preparation 
of  this  paper. 


56 

BIBLIOGRAPHY. 

Albert,  E. :  Gegen  die  Castration  bei  Tuberculosa  des  Neben- 
hodens.    Th.  von  Gegenvert.     Berl.  and  Wien,  1900,  N.  F.  ii,  17. 

Audebal,  A. :  De  L'epididymectomie  dans  la  tuberculose  testlcu- 
laire.     Thesis,  Paris,  1S98. 

Barling,  Gilbert:  Clinical  lecture  on  tubercular  disease  of  the 
testicle.     Birmingham  Med.  Review,  1S92,  xxxi,  152-156. 

Bugge,  Jens :  Undersogelser  om  Lungetuberkulosens  Ilyppighed 
og  Helbredelighed,   1896. 

Delore :  De  L'orehidotomie  dans  la  tuberculose  du  testicule. 
Gaz.  hebd.  de  M6d.,  Paris,  1898,  553-556. 

Diuretresco,   T.  :    MSd.   Mod.,   Oct.  2,   1897    (Gould's  Year-BookL 

Duplay,  S.  :    Sem.  M6d..  Aug.  27,  1897   (Gould's  Year-Book ). 

Jacobson  :    Diseases  of  the  male  organs  of  generation,  1893. 

Jarjavay :  Tubercules  du  testicule.  Resection.  Phthisie  pul- 
monale aigue.  Gazette  des  Ilopitaux.  La  Lancette  Frangaise, 
Sept.  28,   1850. 

Koenig :  Beitrag  zum  Studiren  der  Ilodentuberculose.  Deut. 
Ztsch.   f.   Chir.,    Leipz.,   1898,   xlvii,   502-522. 

Longuet,  L.  :  Traitement  chirurgical  de  la  tuberculose  gSnltale 
chez   l'liomme.      Revue   <1  •   <  'Mrurgie,   Paris,   Janvier,   1900. 

Mauclaire :  Traitemci.i  de  la  tuberculose  epididymo-testiculaire 
par  les  ligatures  et  les  sections  des  616ments  du  cordon  spermatique. 
Annales  des  maladies  des  organes  genito-urinaires,  Paris,  1900, 
xviii,   p.   356-413. 

Mynter,  Herman  :  Tuberculosis  of  the  epididymis.  Ann.  of  Sur- 
gery, Phila.,  1893,  xvii,  430-438. 

Northrup  and  Bovaird  :  Quoted  by  Blackader  in  Progressive  Medi- 
cine, March,  1900,   p.  269. 

Parker,  Preston :  Monorchism,  tuberculous  orchitis  and  pros- 
tatitis— fatal  general  tuberculosis.  British  Med.  Journal,  London, 
1892,  i,  p.  118. 

Senn,  N..:    Tuberculosis  of  the  Genito-urinary  Organs,  1897. 

Shaw :  Tuberculosis  of  the  testicle  following  an  attack  of 
measles.     British   Med.   Journal,   1S9S.   i.   1586. 


Reprinted    from 

The  Journal  of  the  American  Medical  Association 

November  10,  17,  24,  31 ;  December  1  and  8,   1900 


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